On 1 December 2017, acting on the recommendation of the Global Fund’s Grant Approvals Committee (GAC), the Board approved two grants emanating from Thailand’s 2017 Window 2 TB/HIV funding request. The Ministry of Health’s Department of Disease Control will serve as principal recipient (PR) for one grant, totaling $18.0 million. The Raks Thai Foundation will serve as PR for the other $19.6 million grant. The total TB/HIV allocation for Thailand is $37.6 million. Both grants were scheduled to begin on 1 January 2018 and are expected to end on 31 December 2020.
In addition to the $37.6 million within-allocation request, Thailand’s country coordinating mechanism (CCM), which developed and submitted the funding request, made a prioritized above-allocation request (PAAR) of $13.3 million. After some adjustments were made and $1.4 million in efficiencies were found in the within-allocation budget, the remaining PAAR interventions, totaling $11.3 million, were added to the register of unfunded quality demand.
This may be the final allocation for TB and HIV in Thailand. But this is the grant that was never supposed to be. In 2014, when it submitted its TB/HIV concept note, Thailand announced that it would be the last time the country requested money from the Global Fund. Following that, in 2015, Thailand received a two-year grant which was intended to support “a planned full transition to domestic funding by 2017.” As of February 2016, Global Fund resources only accounted for about 5% of total TB and HIV funding in Thailand, with the government supplying more than 90% of the funding. Thus, it appeared, Thailand was a stellar candidate for imminent transition out of Global Fund support. But concerns about such an abrupt transition were raised by a number of stakeholders from civil society and other sectors.
At the time, while only 5% of all funding for TB and HIV came from the Global Fund, more than 85% of all HIV prevention funding for key populations was coming from external sources such as the Fund and the U.S. Government. For the Fund to transition out now, or earlier, would likely have left key populations programming in a stunted position. Although the Government of Thailand has been growing its contributions to key population programs in recent years, it hasn’t yet shown that it is ready or willing to take them on fully.
Over the years, in fact, the government has actively resisted providing HIV prevention services to people who inject drugs (PWID) in particular, to the point that the Global Fund made grants to NGOs to carry out needle distribution programs as early as the Round 3 funding cycle (circa 2006; see GFO 65 for details). Other key populations –– i.e. sex workers, men who have sex with men (MSM), and migrants –– would have also been at risk of losing crucial program support if the Fund left. Services for key populations are the heart of the HIV response in Thailand. In 2016, 65% of new HIV infections in Thailand were among these populations. Thus, as the GAC reflected in its 2017 comments: “A responsible transition may require additional time than was initially foreseen.”
It appears that the issue of key populations programs was sufficient to consider additional funding for Thailand. While the Global Fund noted in grant documents that domestic financing for TB grew by 200% between 2015 and 2017 (to $115 million), and that domestic funding accounted for 85% ($782 million) of the overall HIV-related need in Thailand, the domestic funding gap among key populations –– i.e. 85% of the funding coming from external donors –– is significant. So rather than remove all funding, the Fund agreed that funding be continued for a small portion of the response, to “keep the momentum going,” as stated in one grant-related document. At least in part on this basis, the Global Fund Secretariat recommended continuing Thailand’s TB/HIV allocation for the 2017–2019 period.
For the 2018–2020 implementation period of the grants, “keeping the momentum going” means that Global Fund resources will, in addition to supplementing key population investments, support improved sub-national planning and provincial coordination of HIV and TB programs. The objective of these efforts is to improve the application of local epidemiology, mapping and program performance data to resource allocation and management, as well as enhance community engagement in the HIV and TB responses.
As for government commitments to key population programs for 2018–2020, at $42 million they will be more than three times as much as the prior period. Some examples of domestic investment growth are described in the table below. The GAC referred to these increased investments as “strong building blocks” for an inclusive and successful transition. According to a spokesperson of the Global Fund, while the approved HIV and TB grants are not transition funding, “they are strongly focused on strengthening sustainability and transition preparedness.”
Table: Changes in domestic contribution to key population programs,
as percent of total investment
|Syringe distribution (PWID)||
|HIV prevention (migrants)||
|HIV prevention (PWID)||
|HIV prevention (prisoners)||
Iterated funding request
The original 2017 funding request, submitted in May 2017, described how the HIV funds would be targeted to key populations, including PWID, MSM and sex workers, as well as migrant populations, a major key population for HIV and TB in Thailand. The proposed interventions for key populations included expanded HIV testing, improved linkages among service providers, scale-up of pre-exposure prophylaxis (PrEP), targeted condom promotion, and implementation of syringe distribution programs and opioid substitution therapy (OST) for PWID. The TB request mainly aimed to fill gaps in existing programming related to TB prevention and care, shorter courses of treatment for multi-drug-resistant TB (MDR-TB), and TB among people living with HIV.
That original funding request was reviewed by the Technical Review Panel (TRP) in June 2017 but was recommended for iteration (i.e. returned to the CCM for significant revisions) because the TRP believed that it “did not demonstrate a strategic approach to … overcome significant hurdles necessary to reach 90-90-90 targets amongst key populations, especially people who use drugs.” The TRP was also concerned that the first iteration of the funding request was light on describing how the government was preparing to support community-based HIV and TB services, and how it would work to build national consensus following Global Fund transition. Seven key issues were flagged by TRP in the initial funding request, and were addressed in the second iteration, which was reviewed by TRP in October 2017 and was recommended to proceed to grant-making. A selection of strengths and issues identified by the TRP in the revised version are discussed below.
In its review of the second iteration of the funding request, the TRP indicated a bevy of strengths. Top among these was that the request was “based on objective analysis of the epidemiological situation among key populations.” The weaknesses of the key population situational analysis and respective interventions in the first version was the principal reason it was returned for iteration, so this is an essential improvement. More specifically, the TRP commended the revised request for having some “strong and innovative” HIV interventions, including programming for PWID which was “detailed and more ambitious” than the first version. Increases in programming for MSM, transgender people and prisoners were also highlighted.
On TB, one strength noted by the TRP was the greater clarity provided about the strategy for intensified case finding. According to the revised funding request, intensified case finding would be carried out in health care and community settings, including 132 prisons and 77 provinces in the first year, using Global Fund resources; and then in 36 provinces in the second and third years, using domestic funds. This level of detail is part of what led the TRP to state: “The [revised] funding request clearly describes the transition to domestic financing.”
The reliability of HIV data for key populations was a major concern for the TRP. From its perspective, the data in the revised request was substantially “better” than in the original. But the substantial difference in data between the two versions led the TRP to highlight the need for, “ongoing attention to obtaining and using timely, quality longitudinal data to inform and target programming.”
In addition to the concerns about data reliability for key populations, when it reviewed the original request the TRP expressed concerns regarding the plausibility of PWID’s access to quality HIV services in a constrained legal environment. The TRP felt that inadequate attention was given in the request to addressing the need for ongoing advocacy to make the social and legal environments more enabling for PWID and others to safely access services free from stigma or legal penalty. Partly in response to TRP concerns, the revised request included a range of financing mechanisms for community-based services. But in its second review, the TRP cautioned that many of these approaches were yet untested in the Thai health sector context. Ensuring that these mechanisms are rolled-out and analyzed for ongoing feasibility will be critical to successful program transition from Global Fund to domestic support, the TRP said.