On 31 January 2019, the Global Fund Board approved three country grants worth $13.4 million. It also approved two multicountry grants valued at $22.5 million. The Board was acting on the recommendations of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC). See Tables 1 and 2 for listings of the country and multi-country grants.
By Aidspan’s count, this was the 16th batch of approvals from the 2017-2019 allocations. The country grants emanated from funding requests submitted by the Dominican Republic, Nicaragua and Sri Lanka. Interventions totaling $61,187 from the Sri Lanka request were added to the Unfunded Quality Demand (UQD) Register. Domestic commitments for the programs included in the approved country grants amounted to $97.3 million.
|Amount approved 1||UQD||Domestic commitment 2|
|Dom. Rep.||TB||DOM-T-MISPAS||MSPAS 3||
|Sri Lanka||Malaria||LKA-M-MOH||Ministry of Health||
- Amounts shown are upper ceilings.
- The domestic commitments shown are for the disease programs and exclude RSSH.
- MSPAS = African Ministry of Public Health and Social Assistance | REDNICA = Federación RED NICASALUD
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.
|Principal recipient||Amount approved||UQD|
|Multicountry SEA HIV||QMZ-H-AFAO||AFAO 1||12,500,000||957,220|
|Multicountry TB Asia||QMZ-T-UNOPS||UNOPS 2||9,999,999||6,248,347|
(1) AFAO = Australian Federation of AIDS Organizations
(2) UNOPS = United Nations Office for Project Service
The Global Fund Board also approved funding in the amount of $66.1 million for several interventions on the UQD Register. The funds will be added to eight grants in six countries and to one multicountry grant. The sources of these funds are portfolio optimization, private sector contributions and Debt2Health. See Table 3 (below) for details.
This was the largest award to date for UQD interventions from the 2017–2019 allocations. Previously, the Board approved funding for interventions to be added to the following grants: Burundi malaria, Philippines TB, Rwanda malaria and Pakistan malaria.
In 2018, the Global Fund Secretariat applied the Prioritization Framework approved by the Strategy Committee to prioritize interventions on the UQD Register. The Audit and Finance Committee determined that $250.0 million was available for portfolio optimization. The Board has been awarding funding on a case-by-case basis, aligned with in-country planning timelines and programmatic needs.
|Funding source 1||Amount
|Revised program budget ($)|
|Cameroon 2||HIV||CMR-H-MOH||Ministry of Health||PO||703,555||97,269,756|
|Democratic Republic of Congo||Malaria||COD-M-SANRU||SANRU 3||PO||17,413,509||296,534,487|
|COD-M-MOH||Ministry of Health||PO||8,586,491||83,495,104|
|Haiti||Malaria||HTI-M-PSI||Population Services International||PSC||750,000||22,350,000|
|MC MOSASWA||Malaria||QPA-M-LSDI||LSDI 3||PSC||2,773,488||12,553,488|
|Namibia||TB/HIV||NAM-C-MOH||Ministry of Health||PO||1,599,000||30,731,416|
|Niger 2||Malaria||NER-M-CRS||CRS 3||PO||5,228,806||56,264,071|
- PO = Portfolio optimization | D2H = Debt2Health | PSC = Private sector contribution
- For grants denominated in euros, an exchange rate of 1 euro = 1.1477 dollars was used.
- SANRU = Soins de Santé Primaires en Milieu Rural | LSDI = Lubombo Spatial Development Initiative | CRS = Catholic Relief Services | MoFPED = Ministry of Finance, Planning and Economic Development
In its report, the GAC provided comments on all of the country and multicountry grants for which funding was awarded. Below, we provide a summary of the GAC’s comments.
Country grants funded from the 2017-2019 allocations
Dominican Republic TB (DOM-T-MSPAS)
As an upper-middle-income country with less than a high burden of TB, the Dominican Republic’s allocation for 2017–2019 consisted of transition funding.
The Ministry of Public Health and Social assistance, the principal recipient (PR) for the approved grant, prepared a transition workplan for the 2019-2021 period with the following objectives:
- Maintain and expand achievements made to date in TB control;
- Implement innovative strategies to make public spending more efficient in the national response to TB; and
- Mobilize national resources to ensure a complete transition towards financing the national response to TB with domestic resources.
The goal of the grant, which will be implemented in 2019–2021, is to maintain and expand efforts to control TB during the transition phase using national resources.
According to the country’s National Development Strategy, the Government of the Dominican Republic is committed to increasing health expenditures to 5% of the country’s gross domestic product by 2030. The government projects that health spending as a percentage of overall government spending will progressively increase from 18% in 2016–2018 to 19% in 2019–2021.
The government said that it will significantly increase domestic funding for TB during 2019–2021. According to the GAC, this is supported by the inclusion of the TB program among programs using results-based budgeting and by signed transition commitments.
While the GAC welcomed the government’s “strong commitment” to fulfill its co-financing requirements, the PR has been requested to provide an annual report demonstrating (a) compliance with the requirements; and (b) fulfilment of the key milestones in the transition workplan (including progress on gradually transferring the costs of Global Fund–supported activities to the national budget).
The transition workplan calls for (among other things) improving procurement processes to avoid stock-outs; and improving treatment outcomes.
The GAC acknowledged that challenges were anticipated with respect to the PR’s capacity to achieve inter-institutional agreements with other government agencies and to efficiently use the available domestic and external resources, but it deemed that the grant’s work plans adequately address these challenges.
Nicaragua malaria (NIC-M-REDNICA)
There has been a steady increase in the number of malaria cases in Nicaragua, from 692 in 2010 to 10,944 in 2017. The malaria grant aims to reduce the number of malaria cases by 90% by 2021.
According to the GAC, starting in April 2018, Nicaragua experienced civil and political unrest, which impacted all Global Fund–supported programs. Between April and July 2018, there were instances of violence and roadblocks across the country. Since then, the programs gradually returned to normal. However, tensions persist, the GAC noted.
In light of this, REDNICA, the PR, is working with another Global Fund-supported program, the Regional Malaria Elimination Initiative (RMEI), managed by the Inter-American Development Bank (IDB), with the aim of maximizing the impact of the interventions of the program funded through this grant while reducing the implementation risks.
Funds from the Nicaragua grant will be used to purchase long-lasting insecticide-treated bed nets (LLINs) and insecticides to be distributed in areas covered by IDB’s financing; and the IDB, in return, will finance some of the activities originally budgeted under Nicaragua’s malaria grant.
In addition to purchasing and distributing LLINs, Nicaragua’s grant will cover indoor residual spraying (IRS) and the scale-up of diagnostic testing and treatment – complemented by community interventions – in eight municipalities with the highest burden of malaria transmission. These municipalities represent more than 97% of all nationally reported malaria cases. The grant will also include LLINs and insecticide for IRS to cover the needs of 28 other prioritized municipalities.
The Government of Nicaragua has committed to increasing domestic financing beyond what is needed to meet its co-financing requirements. Nevertheless, given the political climate in the country, measures have been put in place to monitor the realization of the commitments. The GAC said that the political climate has already led several donors to withdraw their support.
Sri Lanka malaria (LKA-M-MOH)
Sri Lanka has been certified malaria-free by the World Health Organization (WHO) since 2016. This grant is designed to prevent the re-introduction of malaria. It is a transition grant; and it also a national strategy–based grant using a payment-for-results modality, meaning that funds will only be disbursed upon completion of a workplan tracking measures specified in the performance framework.
The GAC said that the grant faces some challenges, including the following:
- There are challenges regarding procurement of small quantities of commodities and health products through domestic funding. The GAC recommended that Sri Lanka make use of Wambo.org, the Global Fund’s online procurement tool.
- There are challenges related to human resources, mainly due to the change from pre-elimination of malaria to elimination and prevention of reintroduction. The government has taken over responsibility for all staff positions, but there is a need to develop a human- resources and capacity-building plan adapted to the ‘prevention of re-introduction’ phase.
Multicountry grants funded from the 2017-2019 allocations
TB Asia UNOPS (QMZ-T-UNOPS)
This grant will address the burden of TB among migrants in the Greater Mekong sub-region, with a particular emphasis on identifying and treating missing TB cases in the participating countries (Cambodia, Lao, Myanmar, Thailand and Vietnam). The main target populations are documented and undocumented cross-border migrants and refugees, both in camps and in urban settings.
The grant has the following objectives:
- Increase the sensitivity of service providers to migrant health;
- Improve access to TB services;
- Strengthen monitoring and evaluation of TB in migrants;
- Support the development of policies and legal frameworks to improve TB care for migrants; and
- Maintain partnerships and multicountry frameworks to support TB care in the region.
The GAC said that there are uncertainties regarding the coverage of health insurance costs by the Government of Thailand, where elections are scheduled for March 2019.
HIV SEA (QMZ-H-AFAO)
This new grant, which covers eight countries in South-East Asia (Bhutan, Lao, Malaysia, Sri Lanka, Mongolia, Papua New Guinea, Philippines and Timor Leste), builds on existing Global Fund-supported programs for key populations and aims to promote sustainable services specifically for key populations at higher risk of HIV exposure.
The goal of the grant is to stop new transmissions of HIV and AIDS-related deaths by 2030. The region not currently on track to meet these goals, the GAC said.
The GAC commended the innovative design of the grant, which facilitates continued financing for advocacy efforts at the end of this grant by securing an additional $2.5 million from external sources prior to the disbursement of the final $2.5 million from the grant itself.
Additional funding for UQD interventions
Cameroon HIV (CMR-H-MOH). The funding ($703,555) will pay for additional viral load tests (50,000 in 2018, 60,000 in 2019 and 80,000 in 2020). The tests will enable the PR, the Ministry of Health, to (a) monitor the quality and efficacy of antiretroviral therapy (ART) for people currently being treated; and (b) conduct early infant diagnosis. The national program reported that 253,000 people were receiving ART at the end of December 2017, up from 206,000 in December 2016 and 154,000 in December 2015. According to a 2016 survey, there are an estimated 560,000 people living with HIV in Cameroon.
Democratic Republic of Congo malaria (COD-M-MOH and COD-M-SANRU). The funding ($20.8 million) will pay for mass distribution of LLINs, particularly in eight of DRC’s 26 provinces (Kongo Central, Kasaï, Kinshasa, Maniema, Tshopo, Ituri, Haut-Uele and Bas-Uele) which have an estimated population of 34.2 million (about 30% of the total population of DRC). Of the $20.8 million in funding, $3.4 million comes from a Debt2Health swap with Spain, which will cancel $8.3 million in bilateral loans owed by DRC. The bed-net campaign is also supported by the Against Malaria Foundation (AMF) which is donating 11.7 million LLINs.
The above investments, coupled with contributions from the (U.S.) President’s Malaria Initiative and from efficiencies in grant implementation, will enable DRC to maintain universal bed-net coverage and ultimately contribute to reducing incidence and mortality rates by 40% (key objectives of the 2016-2020 national strategic plan).
Haiti malaria and TB/HIV (HTI-M-PSI and HTI-C-PSI). The malaria funding ($750,000) will allow Haiti to increase coverage of bed nets distributed routinely to pregnant women attending ante-natal clinics that are situated in areas with high risk of malaria transmission, and are not covered by the current grant. The HIV portion of the $2.3 million for TB/HIV focuses on pregnant women and aims to increase adherence to treatment and improve treatment outcomes. Community health workers will include active case finding of an estimated 4,000 pregnant women lost to follow-up on ante-natal care. In addition, support groups for HIV-positive women who have recently given birth will be created.
The TB portion will fund community health workers (CHWs) to perform outreach activities and actively search for people showing signs of possible TB infection. The CHWs will link them with health centers where they can get tested and, if appropriate, treated. Particular emphasis will be put on ensuring isoniazid preventive therapy (IPT) for an estimated 12,957 children who have been in contact with TB patients.
Namibia TB/HIV (NAM-C-MOH). The funding ($1.6 million) will cover the salaries and work of 150 field promoters for two years. In Namibia, given the sparse population and extreme TB burden, field promoters are key to the TB response. They enable Namibia to maintain the achievements in detection rates, to expand TB case finding, and to provide treatment support, including for patients with drug-resistant TB.
In the 2014-2016 allocation period, Global Fund financing supported 510 field promoters. However, the 2017-2019 allocation supported less than one-third that number.
Niger malaria (NER-M-CRS). The funding ($5.2 million) will pay for seasonal malaria chemoprevention (SMC) drugs in 2019 initially planned to be funded by the Crush Malaria Initiative (CMI). This will allow CMI to fund a portion of the SMC gap in 2020 (reflected in other initiatives on the UQD Register). The SMC drugs will enable Niger to reduce under-five mortality rates, a top priority for its malaria programs.
Uganda HIV (UGA-M-MoFPED). The funding ($23.4 million) will ensure (a) improved access to and use of condoms for high-risk sex; (b) greater availability of HIV test kits; (c) improved program capacity for HIV testing; and (d) improved access to and retention in care and treatment through strengthened differentiated-service delivery models.
MOSASWA malaria regional grant (QPA-M-LSDI). This grant is a public-private cross-border initiative involving Mozambique, South Africa and eSwatini (formerly Swaziland). The funding ($2.8 million), which was contributed by the Gates Foundation, will enable the grant to expand IRS activities, CHW programs and IEC/BCC programs. (IEC = Information, education and communication; BCC = behavior change communication.) The programs supported by the MOSASWA grant will also receive catalytic funding from the Global Fund’s 2017-2019 allocations.
In GFO 349, Aidspan reported on the 15th batch of grant approvals. 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-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.