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Global Fund Observer

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Issue 261: 26 February 2015

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CONTENTS OF THIS ISSUE:

1. NEWS: Scale, sustainability and scope in concept notes queried by TRP

In an exhaustive consideration of the 91 concept notes submitted during windows 3 and 4, the Technical Review Panel flagged a number of concerns about both quality and content of the submissions from countries under the NFM. Identifying what they saw as a growing dependence on the Fund for financial resources to maintain their programs for AIDS, TB and malaria, the TRP advised countries that sometimes realistic was better than ambitious -- a decided deviation from the rhetoric from the Fund itself.

2. NEWS: The “fair share” of shared responsibility: domestic financing and the sustainability of Global Fund- supported programs

Since 2008, donor funding for AIDS, TB and malaria has reached a plateau. This is in part due to the global financial crisis, but it also reflects the growing recognition that domestic funding is needed for a sustainable health response. 

3. NEWS: OIG says national strategy financing model pilot in Ethiopia should not proceed at this time

The Office of the Inspector General says that neither the Global Fund Secretariat nor Ethiopia have the necessary systems in place to allow for a national financing strategy model to be implemented at this time. The Secretariat acknowledges that more work is required before it can proceed with this project.

4. NEWS: Global Fund will seek reimbursement from Nigeria's national AIDS agency following contract violations found by OIG

An investigation by the Office of the Inspector General recommended that Nigeria's National Agency for the Control of AIDS (NACA) refund $785,906 to the Global Fund after it found irregularities in renovation of medical stores carried out by contractors .

5. NEWS: Georgia CCM pushes ahead with TB and HIV concept notes

Georgia is fast approaching its self-imposed deadline to submit concept notes for HIV and TB grants under the new funding model (NFM). The CCM has organized a civil society forum and stakeholders' consultation workshop to revise the national strategic plans.

6. NEWS: Uganda acrimony over CCM vote ends with agreement on direct representation

A contentious election over representation for key populations on Uganda's country coordinating mechanism has ended with an amicable resolution that activists in Kampala say will help with more effective targeting of Global Fund money to the people who need it most.

ARTICLES:

1. NEWS: Scale, sustainability and scope in concept notes queried by TRP

Lauren Gelfand 25 February 2015

In review of 91 concept notes, the Technical Review Panel highlighted going concerns

The Technical Review Panel (TRP) has released its most comprehensive report yet on the quality and scope of concept notes submitted under the Global Fund's new funding model (NFM), drawing conclusions and identifying trends in the 91 proposals submitted during windows 3 and 4. The report to the Global Fund Board, released ahead of the Strategy, Investment and Impact Committee (SIIC) meeting, flags growing concerns about the scale, sustainability and envisioned success of the activities submitted for consideration for Global Fund support by the country coordination mechanisms (CCM).

Unease that countries were only paying lip-service to the requirements for gender balance and an emphasis on the particular needs of identified key affected populations was apparent. So, too, were fears that countries were neither collecting nor analyzing data appropriately to provide the evidence base for their national strategic plans.

Hoping to tip the balance towards a greater success rate for concept notes -- of the 91 submitted in Windows 3/4, 19 were sent back for revision -- the TRP included a step-by-step guide for CCMs, essentially walking them through exactly what the TRP is looking for in order to approve a concept note.

While the bulk of the 46-page document summarized the trends and deficiencies in concept notes, it also contained a series of recommendations to the Global Fund itself, particularly with respect to the allocation methodology, and again rapped the decision to develop three separate streams of funding -- base allocations, incentive funding and the register of unfunded quality of demand -- as having potentially ruinous consequences for countries.

Below are some of the main points made by the TRP, which build on conclusions drawn in the TRP reports (see articles here and here) that followed a review of concept notes submitted by early applicants and in Windows 1 and 2.

Feasibility, sustainability and scale

Financial sustainability of programming remains a singular concern for the TRP, with the report leading with an observed "growing dependence on the Global Fund to finance and maintain scale-up of HIV treatment, MDR-TB treatment and distribution of long-lasting insecticidal nets for prevention of malaria".

"[U]nless there is a stronger emphasis on financial sustainability, some applicants are approaching the point at which programs will begin to collapse or major components disappear," the report warned, which will not only undermine but potentially reverse gains made in the national battles against the three diseases.

There was also alarm expressed at the low potential in many concept notes for a realistic scaling-up of service deliveries. As an ever-greater number of people begin treatment, the size of the treatment pool is enlarged, leading to a higher burden for maintenance that prevents further expansion. This is most concerning when it comes to those demographic groups that are especially vulnerable to infection, the TRP noted, which may lead to them being "deprioritized in favor of scaling up programs for populations with potentially far less impact on the epidemic".

Long-term planning for sustainable programming was also compromised by unrealistic assessments of system-wide capacity in many countries, the TRP noted. Despite fairly candid appraisals of their own weaknesses in infrastructure and human resources, too many countries were submitting concept notes that implied there would be enough capacity -- both logistical and human -- to meet increased needs of scale and sustainability. Equally, few proposals addressed the "full continuum of care" necessary to manage both the existing disease burden and prevent new infections.

While the TRP noted with appreciation a number of "positive and promising examples" of community system strengthening (CSS) in concept notes submitted in the two windows, the absence of any CSS components in the majority of the proposals  -- and others that deprioritized any CSS work by placing it in the above-allocation section of their proposals -- demonstrates an acute need to refocus efforts in this area.

Finally, there was a noted disjunction between interventions and programmatic challenges -- meaning that while CCMs were good at identifying the gaps in services, they were not adequately providing options to fill those gaps. Across all three disease components and health systems strengthening activities, "stronger situational analysis has not always translated into program interventions and budgets".

One example of this disharmony was explained using a concept note submitted by an unnamed country for a malaria grant. While the CCM clearly identified economic migrants as one group exceptionally burdened by malaria infection, there was very little elaboration in the concept note as to how the country intended to meet the specific needs of economic migrants when it came to malaria prevention.

These worries about sustainability extended to those countries preparing to transition away from Global Fund support, either through becoming ineligible under the new burden/income parameters or because of the changing epidemiology of disease.

Many of these transitional countries failed to include a description of an "exit plan" in their concept notes -- particularly when it came to programs targeting key populations that are currently the responsibility of civil society or community-based groups. While the exit plan is and should be the purview of the country itself, the TRP suggested it should be incumbent on the Global Fund to mandate a clear plan for transition from those countries reaching the graduation phase.

Human rights,  gender and disease-specific concerns

Nearly universally, the TRP found, concept notes failed to adequately propose "meaningful and effective interventions to address human rights barriers". This includes both targeted activities for key populations who, because of stigma and discrimination or a predatory legislative environment, face numerous barriers in access to health services, as well as activities or community-level work to sustain critical enablers.

"The lack of specific activities for key populations in some concept notes suggested to the TRP that, in some cases, human rights issues were not adequately discussed in the process of concept note development and that key populations were not adequately represented in Country Coordinating Mechanisms," the report said.

Similar concerns were echoed in the TRP's observations about activities specifically designed to meet the needs of women and girls. While some concept notes proposed concrete action to target women and girls, too many others "limit[ed] discussion of gender issues to the background section" or offered "generic solutions to address gender-related issues".

This may be partially attributed to the continued lack of sex-disaggregated data in concept notes -- and within the entire Global Fund ecology as a whole -- as well as to what the TRP identified as a "lack of understanding of effective interventions".  How countries -- as well as the partners who are contracted to provide technical assistance in this area -- will evolve their ability to change social norms and endorse more effective interventions going forward remains to be seen.

The Global Fund itself should, according to the TRP, continue to emphasize the need for "social and human rights interventions" while also considering a new requirement for countries that rank poorly on the Gender Inequality Index to address "identified gender issues with concrete activities".

Of the 91 concept notes reviewed during the two windows, 19 were HIV-related including one which, for the first time, demonstrated that "the demands of ART scale-up will exceed available resources within the next year".

The TRP did not elaborate as to which applicant this was but did note that the proposed ART scale-up was prepared "without sufficient consideration of the fiscal constraints faced". This applicant, the TRP warned, was a bellwether for other countries in sub-Saharan Africa where soon ART will not only be unsustainable due to the availability of resources -- both international and domestic -- but will risk crowding out any other programs, including HIV prevention activities, and putting countries in an "ART triage that might produce several negative consequences".

Eighteen TB concept notes were reviewed during the period, the majority of which continued the trend of emphasizing an increase in case notifications in order to fill case detection gaps and address a rising burden of disease.

And while many concept notes addressed MDR-TB and requested funding to expand MDR-TB services, the TRP suggested it would be more appropriate for TB-eligible countries to focus on "the effectiveness and sustainability of their TB programs before scaling up MDR-TB case detection".

For those 20 concept notes from countries required to submit joint TB/HIV concept notes for every proposal that reflected "strong collaboration between the two programs", too many others "still did not reflect the desirable level of coordination, collaboration and integration between the two programs".

There is a persistent perception, among those applicants eligible to submit stand-alone health systems strengthening (HSS) concept notes, that systems are "discrete, almost stand-alone entities". This, according to the TRP, contravenes the need for HSS work to be well-integrated and complementary to the disease focus.

These problems are compounded among those countries identified as "challenging operating environments," where capacity is low and problems immense.

The TRP saw a wide diversity in quality among HSS concept notes, but noted substantial gaps in those submitted from countries identified as challenging operating environments. The TRP is concerned about the capacity of these applicants to develop well-focused concept notes given their challenges and possible capacity gaps. These applicants include countries in conflict or post-conflict settings, with environmental or geographic challenges, or in a fragile state.

Technical support for these countries is critical, the TRP reiterated, and could come from technical partners, other stakeholders or from peers: other countries that have transitioned out of the conflict or post-conflict environment to become a less-fragile state.

Abolish incentive funding, the TRP says. Again.

The TRP used part of the last third of the report to campaign for its most-favored issue: an end to the incentive funding stream and need for applicants to make above-allocation requests. These two components are failing to achieve "the desired outcome of encouraging ambitious, innovative and prioritized interventions" and are, instead, "creat[ing] undue burden on applicants, the Secretariat and the TRP".

Whether from misunderstanding of the complexities of the model, an effort to maximize their allocations, or a host of other reasons, a sizable number of applicants continue to include essential services in their above-allocation requests -- services that could, and should, have been the mainstay of their allocation demand. In having to send these concept notes back, the TRP was contributing to precisely the kinds of delays that the NFM had been designed to avoid.

Nor did the TRP find that applicants were grasping the intricacies of the concept of full expression of demand. "The full expression of demand also creates additional workload for applicants, as it is significant work to articulate the full demand in the modular template and concept note narrative, especially when no funding is guaranteed beyond the allocation," the TRP wrote.

Beyond the administrative impact of the additional streams, the TRP said, was the potential impact on the Fund's relationship with countries, placing a burden of "unrealistic expectations" on the Fund from countries disappointed by their allocation levels which could then lead to "decrease[d] mobilization of domestic financing".  Another damaging consequence, according to the TRP, is that  they may "undermine a country’s interest in meaningfully prioritizing interventions".

To mitigate these potential hazards, the TRP urged a swift but deliberate re-examination of these concepts in order to revise and streamline the processes of the funding model in good time, ahead of the replenishment set for 2017.

"The TRP strongly advises the Secretariat and the Board to clarify the Global Fund’s objectives for the allocation and to re-evaluate the methodology before the next replenishment," the report said. "If the objective of the Global Fund is to reduce mortality and morbidity rather than eradicate diseases, the methodology should more accurately reflect the most strategic investment of resources."

[This article was first posted on GFO Live on 25 February 2015.]

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2. NEWS: The “fair share” of shared responsibility: domestic financing and the sustainability of Global Fund- supported programs

Gemma Oberth 26 February 2015

Since 2008, donor funding for AIDS, TB and malaria has reached a plateau. This is in part due to the global financial crisis, but it also reflects the growing recognition that domestic funding is needed for a sustainable health response. Many affected countries have stepped in to fill the gap, growing domestic investment globally by more than 100% in the last ten years for the response to the three diseases.

Among Global Fund-supported programs, there has been a $3.5 billion (56%) increase in government contributions since 2012 (Figure 1). The surge is most apparent among lower-middle income countries, which have increased their contribution by 81 %.

Figure 1: Increases in domestic investment in Global Fund-supported programs from 2012-2014 to 2015-2017

Yet despite this surge, many programs continue to depend heavily on external donors. Also of concern is how -- and if -- gains in domestic investment will be sustained. What is not in question is the consensus that a system of shared responsibility is needed, where some money comes from domestic sources and some money comes from donors, in order to sustain investments from both.

But what is the “fair share” of shared responsibility?

The Global Fund has made significant efforts to promote shared responsibility using a system called “Counterpart Financing”. This arrangement means that countries must commit a minimum level of domestic resources towards the disease program in order to receive their entire allocation of Global Fund money. The amount that Ministries of Health and Finance must pledge ranges from 5% for poorer countries to 60% for richer ones. Above these minimum levels, countries can demonstrate additional “Willingness-to-Pay” in order to qualify for further Global Fund support.

There are challenges associated with Counterpart Financing, especially in how to monitor it. It is very difficult to track whether or not countries actually fulfil their side of deal. As one Global Fund staff member put it: “The problem is that budgets are very rarely matched by disbursements – what is budgeted for at the beginning of the year seems to have very little bearing on the amount of funding actually received by a ministry or disease program".

George Korah, a senior specialist in health financing at the Global Fund, says that one way to address this challenge is to make sure commitments for counterpart financing are specific and measurable. For example, in Nigeria there is $49 million from the Global Fund that will be released in matching funds once the government spends the same amount on the purchase of bed nets for malaria prevention.

Korah also says that if countries do not follow through, this can be an opportunity for the Global Fund to engage more closely at country level. In the case of Cameroon, government agreed to pay for two thirds of the ARV program, with the Global Fund paying the rest. When it became clear that Cameroon would be unable to meet this commitment, the Fund opened discussion at the provincial level with an array of stakeholders, which Korah said ultimately resulted in improvements to the program overall.

The Global Fund’s Counterpart Financing and Willingness-to-Pay policies are not the only ways to think about how to “split” shared responsibility. Others have asked important questions like “Is there a need to increase domestic financing and why?” and “How can this be done?”

Friends of the Global Fight recently published a report on innovative strategies to raise domestic funds in Africa. Case studies from Kenya, Rwanda, Tanzania and Zimbabwe highlight new efforts to mobilize resources through health insurance premiums, trust funds and income tax levies. Whiteside and colleagues estimate that as much as $15.5 billion in additional domestic resources could be raised each year through mechanisms like these.

Even with domestic investment on the rise, and innovative strategies being employed, there are questions about sustainability. In the most recent report from the Technical Review Panel (TRP), the body which reviews requests for funding sent to the Global Fund, sustainability was flagged as a key issue. The TRP is concerned that countries are proposing aggressive scale-up of programs without due consideration of the financial feasibility. As a recommendation, the report encourages countries to make realistic projections of future domestic investments.

A recent article published The Lancet has done this, estimating future domestic AIDS spending in 12 African countries. The model predicts that in a maximum effort scenario, Botswana, Namibia and South Africa will be able to cover their full AIDS program by 2018. However, even with maximum effort Ethiopia will only be able to pay for 23 percent of its program needs; Mozambique, just 19 percent.

It is important to recognize that efforts toward a sustainable AIDS, TB and malaria response does not just mean handing over programs to domestic bill-payers. There remain substantial gaps in many low-income countries which far exceed their ability to fund locally. Further, there are many critical program needs which governments are reluctant to support at all. These include TB screening in prisons, malaria control among refugees, harm reduction for injecting drug users and HIV interventions targeting men who have sex with men and sex workers. It is vital that any system of shared responsibility includes these vulnerable and marginalized populations, without which no program will be sustainable.

[This article was first posted on GFO Live on 26 February 2015.]

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3. NEWS: OIG says national strategy financing model pilot in Ethiopia should not proceed at this time

David Garmaise 25 February 2015

Secretariat agrees that more work is needed

Neither the Global Fund Secretariat nor Ethiopia have the necessary systems in place to allow for a national financing strategy model to be implemented at this time. This is the conclusion of a pre-implementation review commissioned by the Secretariat and conducted by the Office of the Inspector General (OIG). The review was conducted between September and November 2014. A report on the review was released on 25 February 2015.

The Secretariat has agreed that more work is required before it can proceed with this project.

The national financing strategy model for grant implementation, previously referred to as a “results-based financing model,” emphasizes outcomes and impacts rather than outputs and services provided. The grants are aligned with national systems, and the implementers have more flexibility in how grant funds are used. (There is a national financing strategy pilot currently underway in Rwanda.)

In a briefing note prepared in July 2014, the Secretariat indicated that it planned to move Ethiopia’s malaria component to a national financing strategy model in 2014, and to do likewise with the HIV and TB components in 2015 and 2016.

The plan was to channel funds through the Millennium Development Goals Performance Fund (MDG-PF), a $676 million pooled finding mechanism managed by the Ministry of Health. At the time of the OIG assessment, eleven donors funded the MDG-PF, which is based on a “one budget, one plan, one report” principle.

Even before the OIG began its assessment, the Secretariat had already identified (in its briefing note) six weaknesses in the implementation of Ethiopia’s malaria grants, which it labeled “high risk”:

  • inadequate M&E and poor data quality
  • theft or diversion of non-financial products
  • poor financial reporting
  • treatment disruption
  • substandard quality of health products
  • inadequate principal recipient reporting and compliance

In its assessment, the OIG concluded that the Secretariat did not do enough to mitigate these risks before deciding to implement the national financing model. The OIG said that internal controls in Ethiopia are still "under construction" and that "the assurances over grant objectives were fragmented and uncoordinated".

The OIG said that the proposed model “neither corrects nor provides incentives to correct” known weaknesses, and does not link disbursements to improvements in systems. Nor does it set minimum standards for reliance on national systems.

With respect to internal controls, the OIG made the following observations:

  • Data collection, monitoring and evaluation: Ethiopia’s health management information systems lack robust mechanisms to identify and correct known weaknesses and ensure quality and timely data.
  • Financial management: All levels of Ethiopia’s federal system of government lack controls.
  • Procurement and supply chain management: Mechanisms to review stock data quality and reconciliation between stock levels, stock cards, and health data at facility level are inadequate.

The OIG said that the Secretariat has no mechanism to formally develop and approve new models of grant management, a finding that it said applied both to the proposal for Ethiopia and to the national financing strategy model already underway for HIV grants in Rwanda.

The OIG said that for both pilots, there was no examination of the risks inherent to adopting alternative ways of doing business, and no identification of the level of assurance required to ensure that the strategic objectives will be met.

As a result of the OIG’s findings, the Secretariat said that it will assess the validity of pursuing national strategy financing on a case-by-case basis. It will provide a justification for any pilot projects that will include as a minimum:

  • a full articulation of the rationale used to determine that a particular country is suitable
  • a description of the system of internal controls in place, including critical controls, weaknesses and vulnerabilities
  • evidence that the system of internal controls has been independently and thoroughly tested and that there is a remedial action plan in place to address key weaknesses.

The Secretariat will also implement a mechanism for developing and approving alternative grant management modalities. Should the Secretariat decide to proceed with national strategy financing or another modality in Ethiopia, it will adopt a phased approach.

Ethiopia is a major recipient of Global Fund money. As of November 2014, it had received more than $1.4 billion in grants. For the current period, Ethiopia has been allocated $591 million.

A spokesperson for the Global Fund told Aidspan that the national financing strategy pilot already underway in Rwanda will proceed as planned.

Input from the Technical Review Panel

In a recent report on Windows 3 and 4 of the NFM, the TRP made some observations that were similar to the OIG’s findings. The TRP said that the Global Fund was piloting different models of results-based financing simultaneously without first developing a clear framework to define and explain how each model would work. The TRP recommended that the Secretariat strengthen the evaluation of the models and share the evaluation reports with stakeholders.

The TRP has prepared a paper on results-based financing at the Global Fund. It is included in an annex to the report on Windows 3 and 4.

[This article was first posted on GFO Live on 25 February 2015.]

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4. NEWS: Global Fund will seek reimbursement from Nigeria's national AIDS agency following contract violations found by OIG

Tunde Akpeji 25 February 2015

The Global Fund will seek the reimbursement of some $786,000 that was improperly spent by the Nigerian National Agency for the Control of AIDS (NACA) on a 2011-2013 project to renovate medical stores.

The irregularities were revealed in a report by the Office of the Inspector General on 20 February, released in response to a review request by the Global Fund in May 2013.

NACA was a principal recipient under a grant signed in October 2009, receiving a budget of $1.7 million to improve infrastructure at primary healthcare facilities around the country where ARVs and other medicines for HIV were being distributed by the national health service.

But according to the OIG, not only was the financial management for the project mishandled -- with budget overruns in excess of $700,000 --  but the ultimate quality of the work was sub-par. Eight medical stores in all were renovated and all of them were done poorly. There were nearly $1.5 million in expenditures that were non-compliant with grant agreements; the Fund will look to recover about half due to undelivered services, excessive and unjustified payments to contractors that carried out the renovation, unreimbursed advances and non-compliance with quality controls.

In light of the findings, there will be new layers of oversight by the Secretariat for Nigeria's grant portfolio. Controls and actions introduced include the appointment of a fiduciary agent in order to mitigate collusion and the diversion of funds in future renovation projects. That agent will work closely with principal recipients on the budgets of any renovation work, so as to comply with guidelines on budgeting and reporting that were updated in September 2014.

NACA, too, is now on notice, according to the report, and must demonstrate its commitment to fighting corruption and collusion when it uses sub-contractors.

In comments to Aidspan, the NACA director general, John Idoko, acknowledged there was an acute need to improve NACA's oversight of building contracts and signalled the intention to recoup some of the funds from the contractors themselves.

The agency, too, has taken steps to improve its procurement processes in line with Global Fund rules.

“We have asked [the Bureau of Public Procurement] to use all the power at its disposal to recover the funds from the contractors and sanction the erring officer, including using the anti graft agencies to recover the funds,” Idoko said, while warning that it can be difficult in Nigeria to get individuals to repay misappropriated funds.

NACA said it also changed its policy to stop sourcing procurement officers from the BPP and has now employed its own procurement staff, ending its reliance on pool officers from BPP in addition to training staff on proper use of accounting software to ensure that spending is within budget.

[This article was first posted on GFO Live on 25 February 2015.]

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5. NEWS: Georgia CCM pushes ahead with TB and HIV concept notes

Tinatin Zardiashvili 25 February 2015

Civil society forum and stakeholders' consultation workshops help identify priority areas

Georgia is planning to submit its HIV concept note on 20 April, in Window 6, and its TB note in Window 7 on 15 July. In anticipation, the country coordinating mechanism has scheduled a series of civil society and stakeholder forums for consultation, in order to identify priority areas and high-impact activities that will help the country overcome its concentrated epidemics.

Preparations were in full swing by the end of 2014, with an overhaul of the CCM's administrative management processes. This followed the election in June (see article here) of a new chairperson for the CCM over civil society concerns about conflicts of interest.

The CCM has also benefitted from technical support from the French government's 5% initiative, which has assisted in the development of the HIV concept note. A USAID consultant is assisting with the TB concept note, Aidspan understands from CCM sources.

Country dialogue opened in January, in an effort to identify core priority areas for both the Fund's concept notes and the country's own national strategic plans. A 25 January civil society forum organized by the CCM featured two panel discussions that were facilitated by local NGOs, and attended by people living with the disease, technical partners, the local fund agent and CCM representatives.

The forum was opened by CCM chairperson, Labor, Health and Social Affairs Minister David Sergienko. In emphasizing the power of close collaboration between government and NGO sectors, he urged forum participants not to limit their engagement in dialogue to listing the challenges but by exploring collaborative and integrated solutions. Without full participation from all stakeholders, he added, the epidemics would continue to spread.

Adherence and provider education identified as key TB priorities

The TB panel offered a window into the challenges facing TB advocates, whose network is considerably smaller than the corresponding network of groups working on Georgia's HIV response. The majority of Georgia's TB-related NGOs are funded through USAID.

The main problem identified by the TB panel was adherence to treatment. One in three patients in Georgia fails to complete the course of treatment, and treatment success rates hover below 50%. Part of the problem, according to panel attendees, is the stigma against TB that is perpetuated even by medical personnel. Another element of the problem is the failure thus far by Georgia to integrate TB care into the primary health system.

Education of health workers about TB was mentioned as a priority, helping to build capacity among primary health care doctors and nurses about TB as one of the most prevalent infectious diseases in the country. Strengthening the TB control system was another priority, developing a mechanism by which state facilities are involved. The current system is run by the private sector, and dependent on the goodwill of individual clinics.

A restrictive policy environment complicates the HIV response

The challenges and priorities identified for HIV were primarily related to the restrictive policy environment in which NGOs operate. Georgia's criminalization of drug use and restrictions on harm reduction activities make it difficult for NGOs to effectively target those who are most at risk of contracting the disease. Marry these restrictions with the rising burden of disease -- a prevalence increase from 3.7% to 13% between 2007-2012 among sex workers as just one example -- and Georgian NGOs are looking anxiously at the constraints being built in to the national strategic plan.

Priorities identified during the panel were to maintain existing essential services and boost innovative prevention activities that target key populations. These priorities were corroborated by HIV stakeholders attending a workshop in February that was also financed by the 5% initiative aiming to lock in the key aspects of the national strategic plan.

Enhanced collaboration between HIV and TB work was cited as a critical component of the plan, alongside improved access to opioid substitution therapies for both men and women and better advocacy to open the policy environment to new ways of working.

Sustainability for the Georgian HIV response beyond the life of the Global Fund grants -- and how to shift resource responsibility to government -- was also a hot discussion topic in the stakeholder workshop.

A costed HIV NSP should be finalized and submitted to the CCM by early March, which should have more of a firm delineation of financial responsibility between the state budget and the eventual Global Fund grant. The TB NSP should follow by the end of the month.

[This article was first posted on GFO Live on 25 February 2015.]

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6. NEWS: Uganda acrimony over CCM vote ends with agreement on direct representation

Kikonyogo Kivumbi 12 February 2015

Key population representative will join the CCM

A contentious election over representation by key populations on Uganda's country coordinating mechanism ended on 12 February with an amicable resolution that activists in Kampala say will help to ensure Global Fund-supported activities are more effectively targeted towards the people who need them most.

Representation for key populations -- which in Uganda include men who have sex with men, sex workers, long-distance truck drivers, the fishing community and uniformed personnel -- in the CCM is critical for Uganda's HIV response. HIV prevalence among the MSM community is estimated at over 12% and among sex workers at some 33%. General prevalence in Uganda is 7.3%.

A first ballot in December 2014 saw the election of two members of staff from the Most at Risk Population Network (MARPS Network), which added a second, alternate, seat to the one already held by the network prior to the election. It was later discovered that the two winning candidates were brother and sister as well as colleagues.

The decision not to throw the election open to all interested candidates was roundly decried by the activist community in Uganda, which, despite the criminal penalties imposed on homosexuality and sex work, is thriving and includes a number of civil society Global Fund sub-recipients.

Activists from the lesbian, gay, bisexual, intersex and transgender community have sought representation in the CCM since 2010, according to Sexual Minorities Uganda (SMUG) executive director Frank Mugisha, to make sure that Global Fund-supported activities responded to the needs of those most vulnerable to HIV infection.

To resolve the issue and prevent the internal politics from upending Uganda's efforts to develop its activities portfolio in anticipation of a joint HIV/TB concept note proceeding to grantmaking, the election was annulled a month later by the CCM chair. A second election was set for early February, ahead of which the eight sub-constituencies of key affected populations were asked to each nominate five potential candidates. This electoral slate of 40 candidates would then yield the two representatives for key populations.

Even then, however, there were disagreements over what was described to Aidspan as a heavy-handed role by the MARPS Network in both choosing and approving the potential candidates. The election, set for 5 February, was ultimately boycotted by dozens of activists and civil society groups, primarily those representing Uganda's sexual minorities.

A tense meeting on 11 February culminated with the decision by the MARPS Network representative, Dr Geoffrey Mujisha, to step down from the post he has held since 2013. His sister will remain the alternate member representing key populations. A new representative for key populations was subsequently selected. 

While the controversy over the election sowed a great deal of discord within the civil society actors in Uganda's HIV community, it does demonstrate that countries are working to implement the new minimum requirements established for CCMs as they follow the process from country dialogue through to the submission of their concept notes. Nor should Uganda's challenges be seen as the exception; in neighboring Kenya, a similar election for civil society representation in the CCM was annulled after it was determined that an activist network had trucked in supporters and given them a directive on whom to vote for.

Requirement 1A, "to clearly document efforts to engage key population groups in the development of a concept note" has been found by the Fund to be challenging for countries to achieve. In an analysis referenced as part of the 2014 NFM year in review progress update (see article here), it was found that 59% of concept notes submitted were compliant with the requirement; another 35% were found to be 'compliant with challenges'.

For requirement 1B, "to coordinate the development of concept notes through transparent and documented processes that engage a broad range of stakeholders -- including CCM members and non-members -- in the solicitation and the review of activities to be included in the application", 43% of submitted concept notes were compliant. Another 52% were 'compliant with challenges'.

In overseeing the resolution of the dispute, CCM chairman Vinand Nantulya told Aidspan that it was good that all parties had agreed to work together for the good of the country.

"Uganda is a poor country; the Global Fund money is important for us," he said. "Surely we can sort out this and avoid a protracted war that does not serve anybody any good and actually does harm to our country.“ 

Uganda was allocated $275.6 million for TB and HIV under the new funding model for the period 2014-2017. 

[This article was first posted on GFO Live on 12 February 2015.]

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This is issue 261 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

GFO Newsletter is an independent source of news, analysis and commentary about the Global Fund to Fight AIDS, TB and Malaria (www.theglobalfund.org). GFO is emailed to nearly 10,000 subscribers in 170 countries at least twelve times per year.

GFO Newsletter is a free service of Aidspan (www.aidspan.org), a Kenya-based international NGO that serves as an independent watchdog of the Global Fund, and that provides services that can benefit all countries wishing to obtain and make effective use of Global Fund financing. Aidspan finances its work through grants from foundations and bilateral donors.

Aidspan does not accept Global Fund money, perform paid consulting work, or charge for any of its products. The Board and staff of the Fund have no influence on, and bear no responsibility for, the content of GFO or of any other Aidspan publication.

GFO Newsletter is now available in English and French. Articles are also available in Russian and Spanish.

Aidspan Editor-in-Chief: Lauren Gelfand (lauren.gelfand@aidspan.org)

Aidspan Executive Director: Kate Macintyre (kate.macintyre@aidspan.org)

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