Cameroon’s 2017 TB/HIV funding request included a strong focus on communities and key populations. This was a key theme that emerged from the comments from the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) when they reviewed the request.
That’s the good news. The bad news is that for both Cameroon’s TB/HIV and malaria funding requests, some key interventions were relegated to the prioritized above-allocation request (PAAR) due to a lack of available funding.
There is a belief among many stakeholders in Cameroon that their allocation was reduced in 2017–2019. Table 1 shows the allocations for 2014–2016 and 2017–2019 (in U.S. dollars.) (The 2014–2016 allocations were made in U.S. dollars. The 2017–2019 allocations were in euros; the amounts in the table reflect euro–U.S. dollar conversion rates in effect at the time the allocations were made.)
Table 1: Allocations for Cameroon in 2014-2016 and 2017-2019 ($ million)
|Comp.||2014-2016 allocation||2017-2019 allocation|
|HIV||151.9 m||3.2 m||0||155.2 m||94.6 m||8.1 m||102.7 m|
|TB||8.1 m||6.9 m||0||15.0 m||10.6 m||0||10.6 m|
|Malaria||33.3 m||84.8 m||0||118.1 m||69.6 m||0||69.6 m|
|TB/HIV||0||0||0.9 m||0.9 m||N/A||N/A||N/A|
|Total||193.4 m||94.9 m||0.9 m||289.2 m||174.9 m||8.1 m||182.9 m|
EDITOR’S NOTE: The Global Fund Secretariat has warned about the difficulty in making comparisons between the 2014–2016 and 2017–2019 allocations periods, and we have written about this in a GFO article. The 2014–2016 allocations were unique in that they represented a transition between the rounds-based period and the new funding model, and they contained money from both existing grants and additional (i.e. new) funding.
The Global Fund has said that the 2014–2016 allocations were meant to cover four years rather than the usual three. Based on this, the average annual allocation for Cameroon for 2014–2016 was $72.3 million, and the average annual allocation for 2017–2019 was $61.0 million. But even with this adjustment, it is not clear to us whether the two periods can really be compared. We acknowledge, however, that many people are going to make the comparison anyhow.
The Global Fund Board approved two HIV grants and one TB grant on 12 January 2018. Earlier, on 1 December 2017, the Board approved a malaria grant. See Table 2 for more information on the grants.
Table 2: Approved grants to Cameroon
|Component||Name||Principal recipient||Amount (€)|
|HIV||CMR-H-CMF||Cameroon National Association for Family Welfare||21.8 m|
|CMR-H-MOH||Ministry of Health||84.1 m|
|TB||CMR-T-MOH||Ministry of Health||10.0 m|
|Malaria||CMR-M-MOH||Ministry of Health||65.5 m|
|Total||€ 181.4 m|
2. The allocation for Cameroon for 2017–2019 was € 172.1 million. The difference between this amount and the € 181.4 million shown in this table is a € 9.3 million Debt2Health swap initiated by Spain.
Cameroon has an estimated population of 23 million; women of child-bearing age (15–49 years) and children under 5 years of age represent almost 40% of the total population.
The country has a generalized HIV epidemic with a prevalence of 4.3% in the general population aged 15–44 years. The prevalence is 5.9% in women and 2.9% in men. Spectrum estimates indicate a downward trend in prevalence, incidence and mortality, and a decline in HIV prevalence in pregnant women and vertical transmission rates. Though a decline in HIV prevalence has been recorded in sex workers and men who have sex with men, the rates in Yaoundé and Douala have increased and are several folds higher than infection rates in the general population. Key populations have been identified as female sex workers, men who have sex with men, transgender people, people who use drugs and prison populations. Vulnerable populations include people with disabilities, displaced people in refugee camps with higher prevalence, and some categories of workers (industrial plantations, forestry and construction, moto taxi drivers and truckers).
Out of an estimated 560,000 people living with HIV, about 68% percent are aware of their HIV status. Just over half of them (205,800) are on treatment. Among those on treatment, 23% have received a viral load test, and about two-thirds of these achieved viral suppression. Although the prevention of mother-to-child transmission (PMTCT) program has made progress, of the pregnant women attending the antenatal care clinic 12% had not been tested for HIV. Of the pregnant women who were HIV-positive, 25% had not received antiretroviral treatment (ART) and 55% were still monitored after 12 months.
TB incidence and mortality rates declined between 2010 and 2016 (incidence: from 260 per 100,000 to 212; mortality: from 76 per 100,000 to 56). Though there has been an increase in the notification rates for TB in the last 10 years, the treatment coverage was only 54% in 2015, indicating that there a large pool of undiagnosed TB in the community. Screening of high-risk groups contributed to the increase in notification rates. The incidence of TB/HIV co-infection in 2016 was reported as 34%, with 92% of TB patients tested for HIV, and 93% of co-infected individuals receiving ART. Screening of people living with HIV resulted in the diagnosis of 8,200 TB cases in this group in 2016.
Cameroon’s country coordinating mechanism (CCM) submitted a TB/HIV funding request in 2017 in the amount of € 99.0 million, and a matching funds request for € 7.6 million.
Cameroon also submitted a prioritized above allocation request (PAAR) of € 35.9 million, of which the Technical Review Panel (TRP) deemed € 34.8 million to be quality demand. During grant-making, budget efficiencies of € 0.6 million were identified and were used to fund some of the interventions in the PAAR. As mentioned above, another € 9.3 million was received from a Debt2Health swap initiated by Spain; this, too, was used to fund initiatives in the PAAR. In the end, interventions worth € 24.9 million were added to the Unfunded Quality Demand (UQD) Register.
Most of the money invested in PAAR initiatives during grant-making was for starting new patients on ART. Some funding went to the purchase of new mobile digital X-ray machines used in HIV care, and MDR-TB treatments.
The TRP said that the funding request presented a very ambitious plan to drastically scale up all strategies recommended globally to end TB and HIV epidemics.
The focus on communities and key populations was evident from the comments of the TRP when it reviewed the funding request. First, the TRP said that the request provided valuable information on key populations, such as men who have sex with men, and sex workers. The TRP also noted that the proposed modules for key populations were clearly based on this information.
Second, the funding request included a community component that aims to develop and implement an integrated and patient-centered approach. Under this approach, community-based organizations (CBOs) will contribute to TB service delivery through the detection and referral of suspected TB cases, contact tracing for both drug-sensitive and drug-resistant TB, and support for HIV care.
Third, the funding request included new interventions for several key populations, including people who inject drugs; transgendered people; people living with disabilities; and people in prisons. Finally, the funding request proposed establishing care centers dedicated to young people.
Other strengths noted by the TRP included that the funding request called for differentiated diagnostics strategies and treatment approaches to TB and HIV control; and that the request included “a comprehensive combination of activities” to strengthen the diagnosis and treatment of MDR-TB.
Weaknesses and concerns
The TRP listed eight concerns, all of which were discussed during grant-making but not necessary resolved. Specifically:
ISSUE: Limited use of GeneXpert machines. The funding request did not articulate a vision for the use of GeneXpert machines in TB testing.
Outcome: This issue was partially addressed during grant-making. Cameroon will develop a plan that will include a TB diagnosis algorithm for each key population; a description of the TB diagnosis services and quality control procedures; strategies for improving the use of rapid diagnosis recommended by the World Health Organization; and the identification of funding sources and gaps.
ISSUE: Low target for treating diagnosed MDR-TB cases. The target is to enroll 95% of patients diagnosed with MDR-TB on second-line treatment, but it should be 100%.
Outcome: Cameroon confirmed that it plans to treat all MDR-TB cases diagnosed from 2018 on. The CCM said that there had been some gaps in the past between diagnosis and treatment but that corrective measures were implemented.
ISSUE: Lack of differentiation in HIV interventions. The funding request referred to the selection of 38 districts where the Global Fund will invest towards HIV prevention targeting key populations and noted that in some districts there are other donors who fund HIV activities. But the request did not map out the districts where there is complementarity with other donors. Nor did it contain the approach to be used in these districts.
Outcome: This issue was scheduled to be resolved within the first six months of grant implementation. The TRP called on Cameroon to develop a service mapping district by district; and a brief description of the process and time-bound schedule to undertake and complete the district-based strategic differentiation. The TRP also called for an assessment of available human resources and existing skills to be carried out to ensure that district teams are able to handle the workload expected from them.
ISSUE: Module for people who inject drugs not adequately developed. The module is not well-articulated, and the activities and the budget are not aligned.
Outcome: This issue was scheduled to be resolved within the first six months of grant implementation. The TRP called on Cameroon to revise the list of activities and expand the target groups to include people who inject or otherwise use drugs. The TRP also called for the provision of commodities needed to reduce risks.
ISSUE: Late and partial payment of counterpart financing commitments. The funding request contained only partial information concerning compliance with willingness-to-pay requirements. There is a significant risk that co-financing commitments will not be met.
Outcome: (See the section below on co-financing and sustainability.)
ISSUE: User fees may hinder access to services. Out-of-pocket health expenditures in Cameroon are amongst the highest in the region. A number of HIV and TB services are subject to user fees. The equity and coverage impacts of user’s fees were not articulated in the funding request, and the degree to which these interventions are being considered in development of the country’s health finance strategy was not clearly described.
Outcome: This issue was scheduled to be resolved during of grant implementation. The TRP recommended that Cameroon engage with technical partners to finalize its national health financing strategy such that it addresses the impact of user’s fees on patient access to grant-supported interventions.
ISSUE: Targets missing for adolescent girls and young women, and key populations. While the funding request contained information on expected outcomes for the matching fund requests, no increased targets were provided in terms of coverage for specific services.
Outcome: During grant making, targets for adolescents and young people were clarified. Cameroon said that the performance framework for the CMF grant summarized the targets, expected results and the strategies for each intervention financed by matching funds. The interventions include: communication for behavioral change; friendly services for teens; adaptive screening services for AGYW; services for adolescents and young girls living with HIV; combating stigma and discrimination; keeping girls in school; and prevention and treatment of gender-based violence for girls and young women.
In 2017, the CCM submitted a malaria funding request for € 65.5 million. At the time the TRP reviewed the request, Cameroon had not yet submitted its PAAR.
Malaria is endemic and remains a major public-health problem in Cameroon. In 2016, the country reported 1.8 million malaria cases; 29% of deaths in children under 5 were due to malaria. Key programmatic interventions have been implemented throughout the country including long-lasting insecticidal nets (LLINs), seasonal malaria chemoprevention (SMC), and integrated community case management of fevers (iCCM). According to National Malaria Control Program data, outpatient malaria morbidity decreased from 30.1% in 2014 to 23.6% in 2016; and mortality due to malaria decreased from 22.9% to 12.4% in the same period.
The malaria funding request was of the program continuation type, meaning that Cameroon was not proposing significant changes to its program.
Issues and concerns
The TRP identified four concerns, two of which were partially addressed during grant-making.
ISSUE: Failure to meet targets. Despite the progress made in malaria prevention and control, Cameroon has failed to meet targets in the following areas: (a) the proportion of pregnant women attending antenatal clinics who received three or more doses of intermittent preventive treatment (IPTp); (b) the proportion of confirmed malaria cases that received first-line antimalarial treatment according to national policy; and (c) the proportion of health facilities without stock-outs of key commodities. Not meeting these programmatic benchmarks speaks to health systems challenges involving commodity procurement supply chain management; training of health workers in national case management policy; and quality assurance and quality control of diagnostic services.
Outcome: This issue was partially addressed during grant-making. Cameroon explained that under the current grant, the PR is training 2,043 health workers in diagnosis and case management; and that due to the need to prioritize activities based on the funding available under the allocation, the training of additional health workers is being relegated to the PAAR. Cameroon said that under the current grant, 4,892 community health workers (CHWs) provide a range of health services, including promoting antenatal care attendance; that the new grant will support 4,500 of these CHWs; and that support for an additional 4,500 CHWs is being included in the PAAR.
ISSUE: Insufficient engagement of key populations. Given the range of key and vulnerable populations targeted by proposed program activities, the TRP said, more attention should be paid to engaging these populations.
Outcome: Grant documents indicate that this issue was partially addressed during grant-making, but they don’t say how. The TRP had recommended that that civil society stakeholders be more meaningfully engaged in CCMs and in malaria program planning, implementation and monitoring. The TRP also recommended that qualitative and quantitative assessments that speak to the concerns of civil society be conducted. Finally, the TRP recommended Cameroon work with partners to ensure that key and vulnerable populations are targeted with effective interventions, such as providing LLINs and case management services to refugees. These recommendations will be addressed during grant implementation.
ISSUE: Need for more involvement of private sector. Although the funding request mentions the role of the private sector in malaria control, the request refers to “the limited integration of private sector providers.”
Outcome: This issue will be addressed during grant implementation. The CCM and the PR are considering engaging a private sector SR.
ISSUE: Need to engage neighboring countries. Some of the areas of highest malaria incidence in Cameroon border neighboring countries, but there is nothing in the proposed program about engaging these countries.
Outcome: This issue will be addressed during grant implementation.
FUNDING LANDSCAPE, CO-FINANCING AND SUSTAINABILITY
At about € 310 million a year, Cameroon’s health budget is one of the largest in West and Central Africa, but it remains very low in terms of the proportion it represents of government spending (about 5%) and is far below the Abuja Declaration target (15%), grant documents revealed.
To meet its co-financing requirement associated with the 2017–2019 allocation period, Cameroon will need to invest € 32.9 million during the 2018–2020 implementation period of its grants –– over and above the € 40.5 million it spent in 2015–2017. See Table 3 for details.
Table 3: Cameroon’s co-financing requirement for 2018–2020 (€ million)
|TB||2.0 m||2.0 m||4.0 m|
|HIV||25.4 m||17.8 m||43.2 m|
|Malaria||13.1 m||13.1 m||26.2 m|
|Total||40.5 m||32.9 m||73.4 m|
The GAC considers that there is a significant risk that Cameroon will not be able to meet its commitment.
In June 2017, the International Monetary Federation (IMF) stated that the Cameroon economy is facing decelerating growth, declining fiscal and external space, and rapidly rising public debt. According to grant documents,
“The socio economic pressures faced by Cameroon due to the increasing internally displaced people, the presence of Boko Haram in the north, the estimated 2.4 million people facing food insecurity and the increasing tensions between the Anglophone and Francophone regions (several months of unrest, internet stoppage, general strikes and the detention of Anglophone leaders in the Anglophone regions) ahead of the 2018 presidential election could limit the policy space for major reforms in health spending to take place in the next implementation period.”
To mitigate the risk, the Secretariat will implement the following measures (as per the Operational Policy Note on Co-Financing):
- maintain current grant conditions requiring the government to (a) sign a contract with the Global Fund’s procurement service agents (malaria), and (b) use a separate bank account managed by the Caisse Autonome d’Amortissement (a department within the Ministry of Finance responsible for the management of international funds) for government commitments;
- require the use of specific Global Fund counterpart funding budget line items (health products, PSM and salary incentives);
- identify the disease-specific activities to be financed by the government;
- request the government to update its commitment letter to reflect core and incentive co-financing requirements; and
- request the local fund agent to perform annual reviews of the materialization of the co-financing commitments.
The OPN on Co-Financing is part of the Global Fund’s Operational Policy Manual (March 2018), available on the Fund’s website here (look under “Programmatic Documents”). The OPN, which is dated 31 March 2017, is on pp. 105–129.
With respect to measures to support sustainability, Cameroon is in the process of developing a health financing strategy; and the country’s 12-year health systems strengthening strategy has a vision of attaining universal access to quality health services by 2035. A five-year National Health Development Plan was finalized in 2016.
According to grant documents, performance-based financing (PBF) has proven itself relevant in the Cameroonian health sector after five years of experience. The government has mobilized technical and financial support for making PBF a national program. Since 2014, the Ministry of Public Health has been financing PBF in the North West region with an annual contribution of around $1.5 million. Cameroon aims to scale up PBF nationwide by 2020.
To date, the main contributors in the fight against TB and HIV in Cameroon have been the government, PEPFAR (for HIV) and the Global Fund. As part of the efforts to strengthen the sustainability of the program, and increase the financing of the national strategic plans, the Government of Cameroon has actively engaged with other external donors and technical partners including the U.S. Centers for Disease Control and Prevention, Chemonics, France Expertise, Stop TB, TB REACH, UNAIDS, UNITAID, USAID and the WHO. PEPFAR has approved a Country Operational Plan 17 for an amount of $49.6 million, which will enable the government to cover some gaps in terms of prevention (11 districts) and treatment programs (scale-up in two city clusters, 46 sustained districts) for key populations and PLHIV in the Centre, Littoral, South West, and North West regions of Cameroon.