Although the Global Fund’s TB grant in Ukraine is performing adequately, the Global Fund is concerned about deficiencies in the design and management of the TB programme and related health systems in that country. The Grant Approval Committee (GAC) has recommended that a high-level delegation from the Global Fund and its partners undertake a mission to Ukraine to engage in discussions with the highest level of government.
The GAC made this recommendation in the context of its review of a request for continued funding for a Round 9 TB grant. The GAC recommended incremental funding for Phase 2 in the amount of $59.5 million. The Global Fund Board approved the funding on 3 May.
The principal recipient (PR) for Phase 1 of the grant was the Foundation for Development of Ukraine (FDU).
The Round 9 grant is the only grant from the Global Fund for TB programmes in Ukraine. The GAC said that during Phase 1, essential activities were implemented to develop an enabling environment for improved TB control in Ukraine. The grant achieved an A2 rating. The main accomplishments during Phase 1 included the following:
- Support was provided for the development of the national TB and external quality assurance programmes to conduct drug-susceptibility testing.
- Access to high quality TB treatment services was improved for people with limited access to TB health services.
- The capacity of the Ukrainian health system to respond to TB was strengthened.
The Phase 1 targets for multiple-drug-resistant TB (MDR-TB) treatment were not reached due to complications in customs clearance of second-line anti-TB drugs.
The cumulative expenditure rate, taking both PR and sub-recipient expenditures into account, was only 50% at the cut-off date. The GAC said that the under-spending was mainly due to delayed payments for health products, and the late start of the programme.
While acknowledging that performance of the grant in Phase 1 was adequate, the GAC echoed concerns that it said had been raised earlier in a 2010 TB Programme Review conducted by the World Health Organization, namely that: (a) treatment in Ukraine is mainly hospital-based and dependent on the availability of locally-purchased anti-TB drugs; (b) case-detection efforts are diluted by the screening of non-targeted populations; (c) efforts to fight MDR-TB are largely inadequate and are producing additional drug resistance; and (d) collaboration on TB/HIV co-infection is limited.
As a result, the Global Fund is making Phase 2 disbursements for 2014 conditional on the PR delivering a revised strategy for the National TB Programme (2012–2016) that addresses those recommendations from the 2010 TB Programme Review that have not yet been implemented.
During Phase 1, the PR, the FDU, decided to become a full-fledged donor for TB control in Ukraine. As a result, the country coordinating mechanism (CCM) nominated the Ukrainian Centre for Diseases Control (UCDC) as PR for Phase 2. The GAC noted that the UCDC does not yet meet all of the minimum standards for PRs; and that the plan is for the UCDC to gradually take over the PR functions from the FDU. The transition period is expected to last until at least June 2013. The International HIV/AIDS Alliance in Ukraine will remain in charge of procurement and supply until the UCDC has shown that it is ready to take over these functions.
In Phase 2, the focus will continue to be on high-impact interventions such as strengthening the prevention and management of drug-resistant TB, supporting patients and communities, and consolidating the health system’s capacity for successful TB case management – with a special focus on groups at high risk (prisoners, homeless, Roma and persons living with HIV).
Phase 2 will include a strong emphasis on the MDR-TB component. Activities will include procuring second-line drugs and MDR-TB diagnosis tests; providing support for patients to adhere to TB and drug-resistant TB treatment regimens; providing training on MDR-TB case management; and conducting operational research.
Savings achieved during the review of the request for Phase 2 funding will be reallocated to address the significant gap in access to MDR-TB treatment. As a result of this reprogramming, Global Fund investments are expected to cover up to 50% of MDR-TB treatment needs by 2015. When the Global Fund contribution is combined with those of the Government of Ukraine and Médecins Sans Frontières, coverage is expected to reach 74% by 2015.
The GAC said that its analysis of annual MDR-TB treatment targets suggests that the government contribution will flatline at 2,200 MDR-TB patients per year. The technical partners on the GAC emphasised the need to ensure that government contributions to MDR-TB do not remain flat, or decrease, proportional to the Global Fund contribution, over the life of the grant.
In addition, the GAC said that the government should prioritise the development of a new TB services delivery model, one that takes a health system approach and has a greater focus on ambulatory care. To achieve this, the GAC said, the Global Fund and its partners need to build a critical mass of allies to advocate for scaling up TB case control, and improving programme quality and infection control in Ukraine.
Further, the GAC noted that hospitalisation of TB patients accounts for 70% of the government contribution for TB control. The GAC said there is a need for more detailed information on the government’s investments in TB.
In light of these concerns, the GAC recommended that a high level mission of heads of agencies – including the Global Fund Executive Director and GAC Chair, the WHO Director General, and possibly the Administrator of USAID – undertake a joint mission to Ukraine and engage in discussions at the highest political level to push for health system reforms, changes in payment models and development of ambulatory care models for TB control.
Information for this article was taken from Board Decision B28-EDP-19 and from B28-ER-15, the Report of Secretariat Funding Recommendations and Decisions for April 2013. These documents are not available on the Global Fund website.