On 21 December 2018, the Global Fund Board approved 16 country grants worth $229.4 million. It also approved three multi-country grants valued at $24.0 million. The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC).
By Aidspan’s count, this was the 15th batch of approvals from the 2017–2019 allocations, and brings the cumulative amount awarded to date to over $9.5 billion. The 16 country grants emanated from funding requests submitted by nine countries; and one funding request submitted by the Middle East Response (MER) initiative. The MER initiative covers five countries (Iraq, Jordan, Lebanon, Syria and Yemen) whose allocations were pooled to create a single grant.
The $229.4 million for country grants included matching funds requests valued at $18.1 million. Interventions totaling $125.8 million were added to the Unfunded Quality Demand (UQD) Register. Domestic commitments for the programs included in the approved grants amounted to $460.8 million.
An additional $1.6 million was added to the UQD Register from the approved multi-country grants.
Among the country grants, the largest award, $71.2 million, went to Nigeria for two TB grants and a TB/HIV grant. Mali was next with $53.7 million for a malaria grant.
See Tables 1 and 2 for listings of the country and multi-country grants.
Table 1: Country grants approved from the 2017-2019 allocations –– 15th batch ($)
|Amount approved 1||UQD||Domestic commitment 2|
|Angola||TB||AGO-T-MOH||Ministry of Health||7,674,176||10,866,918||22,346,260|
|Botswana||TB/HIV||BWA-C-ACHAP||CONAVIH 9||13,050,005 5||0||225,862,450 4|
|BWA-C-BMoH||Min. of H. & Wellness||4,817,333||0|
|Comoros 3||HIV||COM-H-DNLS||Ministry of Health, Solidarity and Gender Promotion||1,346,017||437,189||1,067,008|
|Dom. Rep.||HIV||DOM-H-CONAVIH||CONAVIH 9||7,557,616||4,458,173||95,080,836|
|Jamaica||HIV||JAM-H-MOH||Ministry of Health||12,030,638 6||2,414,041||31,344,168|
|Kosovo 3||TB||QNA-T-CDF||Community Dev. Fund||1,728,086||0||3,051,755|
|Mali 3||Malaria||MLI-M-PSI||Pop. Serv. Int.||53,654,542||12,430,698||26,378,489|
|Middle East Response||HIV, TB, malaria||QSF-Z-IOM||International Org. for Malaria||36,408,368||32,685,572||0 8|
|Nigeria||TB/HIV||NGA-C-LSMOH||Lagos Min. of Health||5,089,851||61,133,561||0|
|TB||NGA-T-NTBLCP||Federal Min. of Health||36,422,481|
|Sri Lanka||HIV||LKA-H-FPA||Family Plan. Assoc.||3,545,721||191,822||22,019,912|
|LKA-H-MOH||Ministry of Health||3,346,218|
- Amounts shown are upper ceilings.
- The domestic commitments shown are for the disease programs and exclude RSSH.
- For grants denominated in euros, an exchange rate of 1 euro = 1.1313 dollars was used.
- The $225,862,450 shown as the domestic commitment for Botswana includes $209,655,781 for HIV and $16,306,669 for TB.
- The approved funding shown for Botswana TB/HIV includes $2,000,000 in matching funds.
- The approved funding shown for Jamaica HIV includes $2,100,000 in matching funds.
- The approved funding shown for Nigeria TB and TB/HIV includes $14,000,000 in matching funds.
- The co-financing requirement for the Middle East Response grant was waived.
- ACHAP = African Comprehensive HIV/AIDS Partnerships | CONAVIH = Consejo National para el VIH y el SIDA | IDCP = Instituto Dermatológico y Cirugía de Piel | IHVN = Institute of Human Virology Nigeria
As is customary, the approved funding is subject to availability of funding and will be committed in annual tranches.
In its report to the Board, the GAC said that the grants were found to be disbursement-ready by the Secretariat after a thorough review process, and in consultation with partners. During grant-making, the GAC said, each applicant refined the grant documents, addressed issues raised by the TRP and the GAC, and sought efficiencies where possible. The GAC endorsed the reinvestment of efficiencies in one of the following: (a) the same grant, in areas recommended by the TRP; (b) other disease components of the same applicant –– in instances where the TRP did not recommend reinvesting in the same grant; or (c) the general funding pool.
Table 2: Multi-country grants approved from the 2017–2019 allocations –– 15th batch ($)
|Multicountry EECA TB||QMZ-T-PAS||PAS 2||4,998,976||1,004,800|
|Multicountry EECA HIV||QMZ-H-AUA||Alliance for Public Health||13,000,000||546,003|
|M.C. Sup. Labs TB (WCA) 1||QMZ-T-PNT||PNT 3||6,045,626||0|
- For the supranational labs grant, which was denominated in euros, an exchange rate of 1 euro = 1.1313 dollars was used.
- PAS = Center for Health Policies and Studies
- PNT = Programme National contre la Tuberculose de la République du Bénin
In addition, the Global Fund Board approved $599,101 for a Pakistan malaria grant to fund interventions from the UQD Register (see Table 3). The funds for this award come from a portfolio optimization exercise that was carried out for the 2017–2019 allocation cycle. This is the fourth set of interventions to be funded from this exercise. In October and November 2018, the Board approved funding for the first three sets of interventions (see GFO articles here and here).
Table 3: Additional UQD interventions for 2017–2019 funded through portfolio optimization
program budget ($)
Note: 1 DOMC = Directorate of Malaria Control, Ministry of National Health Services, Regulations and Coordination
The GAC report did not say precisely which interventions for Pakistan malaria on the UQD register were being funded. On the latest version of the register, dated 21 December 2018, there are six interventions shown for Pakistan malaria, totaling $7.4 million.
GAC comments on the approved grants
In its report, the GAC provided comments on the grants for the following seven country components:
- Angola TB
- Botswana TB/HIV
- Jamaica HIV
- Mali malaria
- Middle East Response (MER)
- Nigeria TB
- Sri Lanka HIV
In this article, we summarize the GAC’s comments on four of the components: Angola TB, Botswana TB/HIV, Jamaica HIV and Sri Lanka HIV. (See the separate article in this issue on the MER grant.) We plan to publish separate articles on the Mali malaria and Nigeria TB grants in the next issue of GFO.
The GAC report also included comments on three multi-country grants. We plan to publish a separate article on the multi-country grants in the next issue of GFO.
Angola is one of 30 countries with the highest TB burdens. Although Angola recently developed a new TB strategy for 2018–2022, prolonged national stock-outs and structural barriers to accessing TB services have contributed to rising incidence rates.
The Angola TB grant will focus on (a) TB care and prevention; (b) multi-drug resistant TB (MDR-TB) case detection, diagnosis and treatment; and (c) TB/HIV collaborative activities. The grant prioritizes seven provinces most affected by TB and targets key populations, including children under five, prisoners, miners, people living with HIV, refugees, nomads and the elderly.
The TB grant also includes funding for six months of resilient and sustainable systems for health (RSSH) activities as an interim measure pending the resubmission of a separate RSSH funding request in early 2019. These activities, budgeted at $1.6 million, will allow Angola to continue supporting health management information systems, monitoring and evaluation, and supply chain strengthening.
The Government of Angola has made sufficient commitments to meet the co-financing requirements. In the opinion of the GAC, there is only a small risk of the commitments not being realized.
The GAC said that although Angola’s current TB grant did not perform well (see next paragraph), the government, stakeholders and partners have worked together to design the new grant and to ensure that it addresses several structural barriers to accessing and expanding TB services. Angola projects an increase in case detection from 59% in 2018 to 80% by the end of the grant (December 2021); and an increase in the treatment success rate from 66% in 2017 to 79% by the same date.
The fund portfolio manager for Angola, Adriana Jimenez Cuen, told Aidspan that in 2017 and 2018 the performance ratings for the previous grant fluctuated between B1 and B2, and that the most recent rating was B2. There are four possible ratings of performance ranging from A (meeting or exceeding expectations) to C (unacceptable). A B1 rating means that the performance was adequate. B2 means “inadequate but potential demonstrated.”
The GAC acknowledged that the Government of Angola has historically procured first-line TB drugs but said that the country fell short of this commitment in 2017 when it was facing an imminent stock-out and the government was forced to ask the Global Fund to process an emergency procurement.
The GAC recommended that the government use the Global Drug Facility to procure first-line TB drugs. Jimenez told Aidspan that Angola has previously expressed an interest in using the Global Drug Facility, and that it recognized this would allow for “access to more affordable international prices, assured quality medicines and efficient lead and delivery times.”
Jimenez said that the GAC recommendation was intended to reinforce the notion of using the Global Drug Facility and to ensure that future stockouts and emergency procurements are avoided.
Wambo.org, the Global Fund’s own procurement tool, currently does not procure first-line TB drugs.
The GAC said that continued partner advocacy and support is required to ensure a strong programmatic performance during implementation of Angola’s TB grant.
Botswana has a high HIV prevalence rate (22.8%) among persons aged 15–49. TB rates remain among the highest in the world.
The two approved grants will support the goals of ending the TB epidemic: ensuring zero new HIV infections, zero AIDS-related deaths and zero discrimination by 2030.
Botswana received matching funds for two priority areas: Human Rights ($1.0 million); and Adolescent Girls and Young Women (AGYW; $1.0 million).
In order to be eligible for matching funds, applicants need to meet four conditions:
- The program associated with the 2017–2019 allocation includes activities that support the specific strategic priority area;
- The investment in the priority area is higher in 2017–2019 compared to 2014-2016;
- Funding from the 2017–2019 allocation invested in the priority area is at least equal to the matching funds requested (i.e. at least a 1:1 ratio); and
- The initiatives proposed under matching funds have clear potential to accelerate progress in the relevant priority area and to maximize impact of the overall program.
Botswana met all of the conditions for the Human Rights funding, but only three of the four conditions for the AGYW funding. Botswana did not meet the condition on increasing the overall investment in AGYW in the 2017–2019 allocation period compared with its 2014–2016 investment.
The GAC approved an exception to this condition. It said (a) that Botswana fell short of meeting this commitment by a small amount; (b) that as a portion of its allocation, the investment in AGYW activities was actually higher in the 2017–2019 period because Botswana experienced a slight reduction in its allocation for that period; and (c) the matching funds are expected to have a catalytic impact on the program.
The GAC said that the Government of Botswana has submitted indicative commitments sufficient to meet the co-financing requirements. The GAC judged the risk of the government not meeting these commitments to be low.
The GAC described Jamaica as having a mixed HIV epidemic with a low-level generalized epidemic (1.7% prevalence) and concentrated epidemics among female sex workers (2%), men who have sex with men (33%) and transgender persons (45%).
The grant aims to:
- Increase access to comprehensive prevention services to reduce new HIV infections and STIs among key populations;
- Scale up HIV testing targeting key populations to identify new cases and provide timely linkage to treatment and care;
- Improve access to HIV treatment and care services through the protection and promotion of human rights for key populations;
- Provide a comprehensive package of care to improve linkage, retention and adherence;
- Increase the capacity of people living with HIV, civil society organizations and key populations to engage in partnerships, advocacy and monitoring of service provision and delivery; and
- Improve the availability of strategic information to guide program development, implementation and evaluation.
The Government of Jamaica has committed sufficient funds to meet the co-financing requirement.
Jamaica received matching funds for two priority areas: Key Populations Impact ($1.1 million) and AGYW ($1.0 million). The TRP recommended the matching funds because of their catalytic potential even though Jamaica did not meet all of the conditions. The TRP waived the condition that the investment in the priority area be higher in 2017-2019 versus 2014-2016. Here are two reasons why:
- For the Human Rights priority area, the TRP said that “given the reduction in allocation when compared to the 2014-2016 allocation, meeting the 1:1 condition would entail close to a 400% increase in investment.”
- Along the same lines, for Key Populations Impact the GAC said that Jamaica was unable to meet the increase in allocation condition given that the investment in key populations in the 2014-2016 allocation period was larger than the entire HIV allocation for 2017-2019.
Table 4 shows the allocations for Jamaica HIV in 2014-2016 and 2017-2019.
Table 4: Allocations for Jamaica HIV: 2014–2016 vs 2017–2019
|Allocation for 2014–2016 ($)||Allocation for 2017–2019($)|
|Existing funding||Additional funding||Incentive funding||Total||Base funding||Matching funds||Total|
|4.2 m||14.9 m||NIL||19.1 m||9.9 m||2.1 m||12.0 m|
The GAC expressed concern about what it considered to be a low coverage rate, slow scale-up and limited government financing in Jamaica’s program. It said that there is a need for more ambitious scale-up targets and for continuing to invest in improving program quality. The GAC observed that Jamaica’s poor fiscal environment is hampering progress. The GAC also noted that the combined Global Fund and government investments are not sufficient to cover “a program at scale.”
Sri Lanka HIV
Sri Lanka is a low-prevalence country. Surveys show an HIV prevalence rate of less than 1.0% in the general population and 1.5 % among men who have sex with men.
The Board approved two grants to be managed by the Ministry of Health, for the first grant, and the Family Planning Association of Sri Lanka for the second.
The grants aims “at working towards” ending AIDS by 2025 with a focus on HIV prevention among key populations. Strategies for achieving this goal include the following:
- Preventing new infections of HIV and STIs among key populations and the general public;
- Providing universal access to HIV and STI diagnosis and treatment, and care and support services for those infected and affected;
- Strengthening strategic information systems and knowledge management;
- Strengthening health systems at different levels; and
- Providing a supportive environment to enhance access to and delivery of HIV prevention, diagnosis, treatment and care services.
The Government of Sri Lanka has committed sufficient funds to meet its co-financing requirement.
The GAC noted that for several years, there have been outstanding recoverables associated with the Sri Lanka portfolio. “Given the considerable efforts already expended by the Secretariat and the low likelihood of recovery,” the GAC stated, “in October 2018, the Executive Director approved the Recoveries Committee’s recommendation to apply a 2:1 reduction amounting to $129,444 to Sri Lanka’s 2017–2019 allocation.” The GAC noted that the budget of the LKA-H-MOH grant has been adjusted to reflect this. A similar reduction will be applied to Sri Lanka’s TB grant that was approved by the Board in November 2018.
The Secretariat informed the Board that it has approved a 12-month extension for a regional grant, Multi-Country Southern Africa ARASA (QPA-H-UNDP), to allow the regional program, which was funded from the 2014-2016 allocations, to transition away from Global Fund support. The extension budget is $1,657,431. No additional funding is involved. The GAC recommended that the PR, UNDP, should make a special effort to ensure that capacity and implementation are transferred to local entities so that activities can continue once the grant ends.
In GFO 345 and GFO 347, Aidspan reported on the 12th, 13th and 14th batches of grant approvals and also listed the grants approved in the 10th and 11th batches. Aidspan reported on the ninth batch of grant approvals here; that article contains links to GFO articles on the first eight batches.
Most of the information for this article was taken from Board Document GF-B40-ER2 (“Electronic Report to the Board: Report of the Secretariat’s Grant Approvals Committee”), undated. This document is not available on the Global Fund website.