The Global Fund Board has approved additional funding for portfolio optimization, funded from the Register of Unfunded Quality Demand (UQD), in the amounts of $135,666,553 and €25,693,664, for 28 grants in 23 countries. The funds come from $650 million approved by the Audit and Finance Committee for portfolio optimization to fund high-impact interventions from the Register of Unfunded Quality Demand, linked to grants in the 2017-2019 funding cycle. The additional amounts will be integrated into the 28 existing grants through grant revisions that increase each grant’s upper-ceiling amount.
The Board’s funding decision was approved by electronic vote on 13 February 2020. The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC).
Table 1: Funding approved for portfolio optimization (UQD) interventions 1
(1) The funding source for all grants in the above table is $650 million approved by the Audit and Finance Committee for portfolio optimization for grants in the 2017-2019 funding cycle. Totals not shown in this table due to mix of USD and EUR denominations, indicated individually per grant.
(2) Economic Relations Division within Nepal’s Ministry of Finance.
(3) RSPCMT is the Republican Scientific and Practical Center for Medical Technologies, Informatization, Administration and Management of Health.
(4) MoFPED is Uganda’s Ministry of Finance, Planning and Economic Development.
(5) This refers specifically to the Department of Disease Control within Thailand’s Ministry of Public Health.
In its report to the Board, the GAC provided comments on the awards, which we summarize in the balance of this article. Given the high number of grants involved, we provide very brief explanations of each, with a small number of others selected for fuller description.
Grant revisions – integration of additional funding from private sector
Papua New Guinea malaria. 94% of the country’s population lives in malaria-endemic areas, and PNG has one of the highest malaria burdens outside of Africa. Against this backdrop, PNG’s national malaria control program had made what the Global Fund has called a “historical achievement” in reducing the number of malaria cases and deaths through national mosquito-net distribution campaigns. Increasing malaria prevalence in the last three years, however, as a result of a widespread resurgence in malaria, threatens this progress, and PNG is now re-intensifying malaria control.
The $2,628,000, which will be used to fund strengthened vector control, will come from Comic Relief’s Red Nose Day Fund. The additional funding will cover the procurement of 245,000 single-size long-lasting insecticide nets (LLINs) for distribution to mothers attending antenatal clinics, as well as the procurement of 138,000 extra-large LLINs for mass distribution. Some funds will also be used to support other aspects of PNGs malaria control program, implemented by the Rotary Club of Port Moresby.
Additional funding awarded for portfolio optimization interventions from the Register of Unfunded Quality Demand
Afghanistan malaria. The additional portfolio optimization investment will support LLIN procurement and distribution through mass campaign and antenatal care services, in order to meet coverage gaps due to underestimation of the population.
Bangladesh TB. The additional funding will support the rollout of a new diagnostic algorithm introduced by the national TB program in 2017, by financing procurement of 132 GeneXpert machines, 40 digital X-ray machines, and 558,555 GeneXpert cartridges, as well as site renovation, infrastructure maintencance, software, training, and project management. This will mean that 469 of the 650 sites targeted in the National Strategic Plan will be equipped with GeneXpert machines by the end of 2020.
Bangladesh HIV. The additional funding will scale up opioid substitution therapy (OST) coverage, which currently is low (5.1% of people who inject drugs).
Bangladesh malaria. The additional funding will cover the cost of LLIN campaigns (703,500 nets) in hotspots in low malaria transmission areas.
Belarus TB/HIV. Belarus has one of the highest levels of rifampicin-resistance/multidrug-resistant TB (RR/MDR-TB) ever recorded; as Belarus has already started to transition towards the new WHO-recommended MDR-TB treatment regimens, the additional funding will support the treatment transition for all eligible patients between 2020 and 2021. It will also cover the procurement of MDR-TB drugs (including Bedaquiline, Cycloserine, Delaminid and Linezolide) for the treatment of additional pre-extensively drug-resistant TB (pre-XDR) and XDR patients using new regimens.
Benin HIV. The additional investment will pay for 200 peer educators/mediators in 2020 (the same as those supported by the Global Fund in 2018 and 2019) who assist key populations and people living with HIV (PLHIV) with adherence to treatment.
Burkina Faso malaria. The portfolio optimization funding will help cover gaps in Artesunate and Artemisinin-based combination therapy (ACT) for the 6,880,693 confirmed outpatient malaria cases in public-sector facilities and the 1,214,240 confirmed malaria cases in the community.
Burundi malaria. As in many countries, Burundi is experiencing an upsurge in malaria cases; this additional funding will cover the costs of additional antimalarial drugs for 3,445,549 patients and rapid diagnostic tests for 4,586,781 people.
Central African Republic malaria. A population increase, thought to be the result of returning refugee- and internally displaced populations to their villages, has led to increased treatment needs at the health facility and community level. The additional funding aims to provide 752,300 additional LLINs, to complete the campaign in targeted regions.
Chad malaria. The additional funding will fund Chad’s 2020 LLIN mass distribution and 2020 Seasonal Malaria Chemoprevention (SMC) campaigns, including 2,906,337 LLINs for six additional regions, and reaching an additional 700,000 children. Current Global Fund grant along with government funding only allows for coverage of 13 out of 19 regions for the mass distribution campaign, and of 39 out of 60 districts eligible for the SMC campaign.
Kyrgyz Republic TB. This additional funding will be combined with a previous portfolio optimization award to support the country’s transition to the 2018 WHO MDR-TB treatment guidelines, enabling it to meet the target number of people with RR- and/or MDR-TB who have begun second-line treatment. Kyrgyz Republic is a high MDR-TB burden country, at 30% among new cases and 68% among previously treated cases.
Lesotho HIV. Lesotho has made “noteworthy progress” against HIV but still has a prevalence rate of 25%, the second-highest in the world. This funding will address an emerging gap in availability of antiretrovirals (ARVs), which is the result of an unexpected government budget shortfall for 2019/2020. The funding will be used to procure ARVs, ensure full transition to tenofovir/lamivudine/dolutegravir combination for all patients, and prevent ARV treatment disruption for 275,941 people. Lesotho is on track to reach the UNAIDS 90-90-90 target by 2020.
Madagascar malaria. The additional funding will support the advance procurement of LLINs for the 2021 mass distribution campaign. This will address a misalignment in funding between preparatory activities and the procurement and distribution of nets; Madagascar’s LLIN mass campaign previously straddled two allocation periods.
Mongolia TB. The funding will address programmatic gaps by supporting the acquisition of 12 GeneXperts and 11 mobile digital X-ray units – essential for the country’s nomadic population (Mongolia has the lowest population density in the world).
Mozambique HIV. The portfolio optimization funding will ensure a continuous supply of ARVs throughout 2020, keeping at least 6 months’ stock in the ARV pipeline to ensure continuity of services for people on treatment. The context for this is Mozambique’s rapid scale-up of treament from 300,000 people in 2012 to more than 1.2 million by mid-2019. The country has plans to reach 1.69 million people on ART by the end of 2020, which would mean that 72.6% of PLHIV will have treatment coverage.
Nepal HIV. Neither migrants nor prisoners in Nepal receive HIV services, though 75% of new HIV infections in Nepal come from returning migrants and their spouses, and prisoners have been defined as a high-risk group. The additional funding will support the scale-up of HIV prevention services and linkages to treatment and care among migrants and prisoners, starting in 2020.
Nepal malaria. The additional investment will support the coverage of 180,000 at-risk and vulnerable populations with LLINs. Government has committed to eliminating malaria by 2024 but outbreaks recorded in 2018-2019 in previously ‘malaria-free’ areas emphasized the need for closer surveillance.
Nepal TB. Nepal needs to strengthen TB diagnosis, given the current inadequate access to rapid diagnosis, and a range of issues with sample transportation and quality assurance of laboratory services. The portfolio optimization funds will address identified gaps in RB diagnosis and case finding, aiming to increase case notification by 8,000 (the estimated number of missing people with TB is between 5,000 and 12,000). Survey results due to be published in March 2020 suggest that the overall TB burden is “significantly higher” than previously estimated.
Papua New Guinea TB/HIV. PNG is among the 14 highest triple-high-burden countries in the world, and has high TB/HIV co-infection rates. In 2018, PNG’s HIV program and WHO conducted a drug resistance study that showed resistance of 18,4% to first-line drugs. The portfolio optimization funding will support the switch of 29,420 PLHIV on ART to the WHO-recommended dolutegravir (DTG)-based ART regimen.
Philippines HIV. The current Global Fund HIV grant to the Philippines focuses mainly on prevention among key populations, with Government covering ARV costs. The portfolio optimization funding is a one-off investment to support the fast transition to Tenofovir/Lamivudine/Dolutegravir (TLD) ART regimen due to constraints linked to the Government budget cycle. The transition will support treatment for up to 13,000 patients, and provide viral load tests for 40,000, among other program enhancement measures.
São Tomé and Príncipe TB. Though malaria transmission here is moving towards elimination, a 31% increase in the annual number of cases was observed from 2016 to 2018. The additional funding will support WHO’s recommended indoor residual spraying (IRS) of the 3 districts where the majority of those cases originated, covering an additional 26,504 households, to reach 85% of households targeted for IRS.
Tajikistan HIV. The additional investment will help cover gaps in HIV prevention and treatment in Tajikistan, by enrolling 1,200 PLHIV on ART and providing counselling and support to increase adherence. In addition, the funding will support the expansion of opioid substitution therapy by 300 people, programs to reduce human rights-related barriers and reduce stigma, and integration of HIV services into the primary health-care system.
Thailand TB/HIV. The additional funding will support Thailand’s transition to the new WHO-recommended RR/MDR-TB regimen starting in 2020. It will also be invested in supporting intensified TB case finding, comprehensive treatment and care among migrants/refugees, and comprehensive treatment of TB infection among children in contact with index TB cases, as well as some procurement of GeneXpert cartridges.
Togo malaria. Togo’s limited funding resources and shortage of medicines have restricted its scale-up of Seasonal Malaria Chemoprevention (SMC), despite having shown “extraordinary results” in the reduction of malaria incidence, malaria prevention, and reduction in children-under-5 mortality. The additional fundw will be used towards scaling up SMC in 2020, aiming to cover 100% of all children at risk in eligible regions (483,411 children).
Turkmenistan TB. The additional portfolio optimization funding will cover the procurement of Bedaquiline for the country’s MDR-TB patients, the procurement of second-line drugs for children (there is an increased number of DR-TB cases diagnosed in children) and of second-line drugs for XDR/pre-XDR cases. This will address the budget gap that now exists due to the initiation of Turkemnistan’s transition in 2019 to the new WHO MDR-TB guidelines.
Uganda TB. Uganda’s own 2015 prevalence survey showed that it is among the top 20 countries for missing TB cases (40,000 every year). The portfolio optimization additional funding will further support the scale-up of Active Case Finding, procure GeneXpert cartridges, and finding TB cases among PLHIV as well as in key populations such as prisoners. The expectation is that by the end of 2020, the number of notified cases of all forms or TB (bacteriologically confirmed and clinically diagnosed) including both new and relapse cases will increase by 12%.
Zambia malaria. The additional funding will address the gap in Zambia’s 2020 LLIN mass campaign in fully covering at-risk populations. The funding will provide 4,872,457 LLINs for the 2020 campaign.
The information for this article was taken from Board Document GF/B42/ER03 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.