On 5 April 2016, GFO reported that $630 million in funding had been approved by the Board. In this article, we provide additional details on the funding awards to some of the countries. (See also a separate GFO article on the award to one particular country: South Africa.)
Tanzania was awarded $162.4 million for a malaria grant, made up of $131.8 million of existing funding and $30.6 million in new money.
Tanzania is one of the biggest recipients of Global Fund investments, with $1.4 billion disbursed to date, and has the third largest population at risk of malaria in Africa. According to the Grant Approvals Committee, Tanzania has achieved notable improvements in malaria treatment and access to prevention services over the past decade.
The grant, for which the principal recipient is the Ministry of Finance, has a dual focus –malaria control and strengthening health systems. It aims to reduce the average malaria prevalence from 10% in 2012 to 5% in 2016, and less than 1% by 2020. The grant also aims to contribute to the overall health sector goal to reach all households with essential health and social welfare services.
The main activities include the following:
- the provision of long-lasting insecticide-treated nets to 5.1 million pregnant women and infants, in addition to distributing 2.1 million LLINs through school net programs;
- promoting universal access to early diagnosis, treatment, and provision of preventive therapies to vulnerable groups;
- training health facility workers in timely submission of logistics management information systems reports; and
- providing grants to 1,910 students to ensure distribution of health staff to remote areas.
The report from the GAC mentioned the recent audit by the Office of the Inspector General on grants to Tanzania (see GFO article), which identified a number of weakness in controls, and listed the management actions that have been agreed to by the OIG and the Secretariat to address the audit findings.
The Tanzania malaria concept note was originally reviewed by the TRP in Window 7 in September 2015. The TRP recommended that the allocation request proceed to grant-making at that time, but that the above-allocation request be considered for incentive funding only after further clarifications were submitted in Window 8 in November 2015. Following the TRP review in Window 8, the GAC awarded incentive funding of $27.7 million. This means that most of the $30.6 million in new money for Tanzania came from the incentive funding pool. The incentive funding will be used to invest in health information and procurement and supply management systems as well as purchase of additional LLINs which are critical for covering all pregnant women and infants at risk of malaria.
In light of the compressed timeframe between the award of incentive funding and presentation of the full grant for GAC review, the Secretariat has included conditions precedent to the use of the incentive funding amount involving delivery by the PR of a detailed workplan and budget for the first quarter of 2016.
It appears from the GAC report that the GAC rejected the advice of the TRP that that entomological monitoring be removed from the allocation funding request. GAC partners were of the view that entomological monitoring is crucial and expressed strong support for maintaining this monitoring in the above allocation request and for adding it to the country’s unfunded quality demand. Entomological monitoring involves detecting changes to insecticide susceptibility. Proponents of entomological monitoring say that the data it produces enables better decision-making about where and with which insecticides to spray.
In March 2016, funding in the amount of $11.5 million was awarded to the Cameroon National Association for Family Welfare, for an HIV grant. This complements funding in the amount of $82.9 million awarded to the Ministry of Health for an HIV grant in 2015. At that time, a further $6.4 million was awarded to the MOH for TB programming.
The Cameroon HIV program aims to reduce new HIV infections by 50% by 2017. Cameroonian law criminalizes sexual relations between people of the same sex, and sex work is banned. Although sex work is still tolerated to a relative degree, the restrictive legal environment in which men who have sex with men live compromises respect for and protection of their right to health and related rights. Due to the restrictive laws, it is difficult for these groups to obtain legal recognition as associations, which restricts the community contribution to the provision of the package of prevention and treatment services. To mitigate and address these issues, this grant includes the following activities:
- at the central and regional level, targeted advocacy and risk management meetings related to HIV prevention and other interventions for key populations;
- legal support for the implementation of activities for key populations as well as training and advocacy of stakeholders, such as judges, officials of the judicial police, traditional authorities, and journalists, on human rights issues and access to health services for key populations; and
- institutional capacity-strengthening of a key population organization for decreasing stigma and increasing key population access to health systems, upon submission of a detailed budget by the PR.
The TB grant in Madagascar received $7.2 million. The goals of the Madagascar TB program are to:
- consolidate treatment success rates for all forms of TB across all regions and strengthen overall TB program management;
- increase the number of TB case notifications each year at a rate exceeding the annual population growth rate; and
- maintain low levels of drug-resistant TB and ensure sustainable care and support for TB patients and families.
When the concept note was first submitted, the GAC felt it should be more ambitious. After grant-making, the Secretariat informed the GAC that the PR (the Office of National Nutrition) did make an effort to increase the targets but that the increase was marginal and that there remained room for improvement. So, according to the GAC report, there is a condition in the grant agreement documents that no disbursements will occur until a strategy on how the grant can be made more ambitious is presented and approved. The strategy may include an increase in targets.
The funding award for the Uzbekistan malaria program was just $400,000, made up of $200,000 in existing funding and $200,000 in new funding. When the allocations were announced in 2014, Uzbekistan received $64.6 million ($56.6 million in existing funding and $8.0 million in new funding). In the suggested disease split provided to Uzbekistan, most of the funds were for HIV and TB. The split showed $1.4 million for malaria ($403,589 in existing finding and $997,530 in new funding).
According to the Secretariat, in its malaria concept note, Uzbekistan applied for $838,806. It is not clear from the GAC report why Uzbekistan applied for less than the disease split indicated it should be entitled to. Perhaps the split was adjusted when the final program split was approved. The Secretariat does not make public information on approved program splits.
Nor is it entirely clear from the GAC report why the funding award was less than half of what was requested. However, it appears to have to do with the fact that thanks to financing from The Global Fund since 2004, Uzbekistan has made significant progress in combatting malaria and is currently in the phase of preventing reintroduction of malaria.
The TRP and GAC recommended that available funds be “refocused” and used as “a catalytic investment” to ensure that resilient and sustainable systems for health are in place to achieve the malaria elimination certification; to ensure implementation of the national strategic plan for malaria; and to ensure that the malaria elimination program establishes robust measures to prevent the reintroduction of malaria.
The GAC report refers to an incentive award in the amount of $400,000 that would be provided to Uzbekistan if the country is successful in receiving the elimination certificate.
Salary top-ups and performance payments
A TB grant in Guinea-Bissau was awarded $3.7 million. In its report, the GAC pointed out that the payment of salary incentives is currently misaligned across the three active grants to Guinea-Bissau. In December 2015, the CCM submitted a proposal for harmonizing the salaries. The goal is to eventually phase them out.
In The Gambia, two malaria grants were awarded a total of $17.3million. The grant for which the MOH is PR includes performance incentives for central government staff. A phase-out plan was agreed which will see a 70% reduction of Global Fund resources for this activity by 2018. The plan stipulates that incentives for relevant positions will be covered by government support from the 2017 budget cycle onwards, with incremental increases and complete takeover of the relevant costs by 2019.
Information for this article comes from the March 2016 report of the Secretariat’s Grant Approvals Committee to the Board (GF-B34-ER12-EDP16-17). This document is not available on the Fund’s website.