Among the grants approved by the Board recently was a multi-country TB grant for the Southern African Regional TB in the Mining Sector (TIMS) Program. In this article, we report on the comments from the Technical Review Panel (TRP) and the Grants Approvals Committee (GAC) on the funding request from which this grant emanated.
Building on the achievements of the current TIMS regional grant (2015–2017), the Southern African Regional Coordinating Mechanism (hereinafter, RCM) submitted a funding request designed to mitigate the consequences of TB among mineworkers, ex-miners and their families and communities surrounding mines in labor sending areas (these are areas from where a significant number of mineworkers have been recruited). There are ten participating countries: South Africa, Tanzania, Botswana, Namibia, Swaziland, Zimbabwe, Mozambique, Malawi, Lesotho and Zambia. The new grant will be implemented by the same principle recipient (PR) that is managing the current grant –– Wits Health Consortium (WHC).
The multi-country grant is among those that the Global Fund describes as pre-shaped –– meaning that the Secretariat directly invited WHC to submit a proposal without going through an RFP process.
According to the GAC, the TB prevalence in these mining areas is about 3–7 times higher than in the general population (in Tanzania, the rate is 20 times higher). HIV prevalence is between 20% and 40%, while TB/HIV coinfection rates are about 50%. There are approximately 3.0 million miners in the region, most of which are located in Tanzania (1.5 million), Zimbabwe (630,000) and South Africa (500,000). These miners are either involved in artisanal and small-scale mining (ASM) or more formal large-scale mining (LSM). The RCM said that the ASM mining sector is mostly illegal and has the poorest working conditions. Miners working in this sector are hard to reach.
The objectives of the multi-country program are:
- to increase TB case finding among key populations (ex-miners and their families, and the communities surrounding the mines);
- to increase the number of people on TB treatment who complete their treatment;
- to increase the number of TB-infected people who are tested for HIV; and
- to increase the number of people co-infected with TB and HIV who are enrolled in HIV and are treated with antiretroviral therapy (ART).
In its funding request, the RCM described two strategies to ensure that these objectives are achieved. The first is the integration of effective regional models of TB care and treatment into national programs. This will be achieved through strengthening TB case finding systems for key populations to ensure that participating countries increase and sustain TB/HIV and occupational health services in their country responses.
The second strategy is to improve and sustain national and local accountability through stronger national policies and corporate responses. This will involve strengthening public and private sector governance, as well as collaboration and coordination among sectors and countries; removing human rights barriers to accessing services; and strengthening cross-border referral systems.
The total of $22.5 million was approved for the new grant. The RCM submitted a prioritized above allocation request (PAAR) of $4.0 million, of which the TRP deemed $2.7 million to be quality demand. During grant-making, efficiencies worth $0.8 million were identified and were used to fund interventions in the PAAR. In the end, interventions totaling $1.9 million were added to the Unfunded Quality Demand (UQD) Register.
Strengths of the funding request
The TRP noted that the funding request is backed by strong political commitment for occupational health services (including TB) to be integrated into national public health services. (During the current grant, 10 occupational health service centers [OHSCs] were set up to provide TB screening and diagnostic services, HIV testing, silicosis screening and diagnosis and to link ex-mineworkers to compensation funds. Of the 10 OHSCs, nine are in countries that did not previously have this expertise.)
The TRP said that the funding request contained innovative TB surveillance and management interventions informed by mapping of the highest disease burden areas. The request also contained interventions targeting hard-to-reach ASM populations which are often missed during routine TB control programs. In addition, the TRP said, the regional and national gaps related to TB case finding and case holding in these mining populations were well articulated.
The TRP praised the RCM for the performance framework and indicators included in the funding request, some of which have been developed specifically for this program. Further, the TRP noted, tools, processes and protocols developed during the new grant implementation period will be linked to national tools so that participating countries can routinely use them. Finally, the TRP said, the funding request emphasizes complementarity, avoidance of duplication, and using lessons learned when scaling up interventions.
According to the grant documents, a portion of the grant funds ($2.1 million) has been allocated to the RCM, which will implement some program activities that are crucial for the success of the multi-country program for several reasons, including: (a) the absence of a regional TB strategy; and (b) the weak engagement of mining companies, labor unions and ex-mineworker’s associations. The country team plans to enter into a separate grant agreement with the RCM to cover these program activities. The GAC emphasized that the separate grant with the RCM will not result in any duplication of activities with the PR.
Issues and concerns
The TRP and the GAC raised several issues, some of which were resolved during grant-making. These issues are described below:
Context-specific interventions. The TRP said that the tools, processes and protocols which will be developed during the next implementation period cannot be one-size-fits-all. It said that the participating countries are not homogeneous and that these tools and processes must be tailored to specific country contexts. To this effect, the TRP requested that the RCM adapt these tools to take into account country-specific contexts and needs. A multi-country meeting was planned for stakeholders to identify approaches for adapting tools and processes to their individual countries. This issue will be fully resolved during grant implementation.
Transition of OHSCs. The 10 OHSCs which were established during the previous grant will be transferred to the respective participating countries’ Ministries of Health during the new grant period. But, the TRP said, the timelines proposed in the funding request were too ambitious: This is a complex process, it said, and will require buy-in from national authorities in the 10 countries. The transfer had been planned for the first year of the new grant. During grant-making, budgets were revised to schedule this activity for the second year of the grant.
Gender-specific interventions are not described. Although the funding request described the gender- and human rights–related barriers to accessing HIV and TB services in its background section, the TRP said that the RCM was not clear on how these barriers will be addressed in the program. The TRP requested that the PR work closely with the Secretariat to articulate the gender-related interventions in the program, including, but not limited to, gender-related barriers to (a) accessing care and disability compensation; (b) sexual and gender-based violence; and (c) sex work. This issue was partially addressed during grant-making. The RCM said that gender-awareness training will be offered to OHSC staff, and that a referral system and network will be developed for referrals to other local community health and community-based organizations. In addition, gender-sensitive policies and practices will be developed for use by mining companies and ex-mineworker’s associations.
Sub-recipient activities are not well defined. This issue was discussed on several occasions during grant-making. The GAC said the fact that sub-recipients (SRs) for the program had not yet been defined made doing detailed budgeting problematic. According to the funding request, the multi-country grant will have two main SRs managing multiple sub-SRs in various countries which will be implementing community services for key populations, supplemented by gender-focused programming. The GAC requested that the Secretariat closely monitor the selection of the SRs to ensure that they (a) have sufficient capacity to implement complex multi-country grant activities; and (b) have a track record of managing different types of health and community services effectively. The GAC added that once the SRs and sub-SRs have been defined and selected, the budgets will be revised to reflect the true operational costs.
A key component of this multi-country grant is strengthening regional platforms and mechanisms in order for participating countries, the private sector and civil society to develop common approaches to addressing TB in the mines. These platforms are designed to ensure full commitment and ownership of the multi-country initiative by the various stakeholders.
Along the same vein, the program uses an integrated implementation approach which will also promote sustainability. Communities will play an active role in implementing TB care and prevention services and health information systems; and in monitoring and evaluating the interventions. In addition, the program components related to resilient and sustainable systems for health –– a combination of community and health systems strengthening interventions –– will help to increase country ownership and capacity.
Finally, a Regional Health Information System (RHIS), which was set up to assist with reporting of TB data for key populations at a regional level, will be hosted by Southern African Development Community (SADC) Secretariat to ensure its sustainability beyond the lifetime of the grant.