Kenya was among the 35 countries that submitted funding requests to the Global Fund in Window 2 on 23 May 2017. Kenya’s TB/HIV funding request was for $421.9 million, made up of a $256.4 million allocation request, $138.9 million prioritized above-allocation request (PAAR) and a $26.6 million matching funds request. A $112.0 million malaria funding request was submitted on the same day ($60.1 million within allocation and $51.9 million PAAR). Both funding requests were full reviews, in accordance with the Global Fund’s new differentiated application process.
“The Funding Request application was jointly developed by an all-inclusive funding request secretariat and writing teams with representatives from national and county governments, civil society organizations, persons living with or affected by HIV, TB and malaria, key populations, adolescents and young people, development and implementing partners, among other stakeholders,” reported a local news outlet.
The HIV portion of Kenya’s TB/HIV funding request is expressly aligned to the country’s HIV Prevention Revolution Roadmap. The Roadmap takes a location- and population-specific approach, tailoring the package of interventions based on the target group and county-level disease burden. The funding request indicates that following the Roadmap is modelled to realize significant efficiency gains, averting an estimated 1,149,000 new HIV infections and 772,000 AIDS-related deaths by 2030 – at no extra cost.
The funding request is also strongly informed by the country’s recent TB prevalence survey; a high-level results summary was released just a month prior to the submission deadline. The survey revealed that the prevalence of TB is much higher than previously thought, at 558/100,000 population, suggesting that a lot of cases are being missed. The burden of TB in men is twice as high as it is in women (809/100,000 compared to 395/100,000) and the majority of TB cases (83%) occur in people who are not living with HIV.
HIV prevention among key populations and finding missing TB cases are heavily prioritized in Kenya’s request. Between the allocation, the PAAR and matching funds, $65.9 million is requested for these priorities. The PAAR activities focus on improving the quality of services provided and strengthening national coordination structures.
The rationale for a focus on key populations and finding missing TB cases is supported by the evidence. The funding request underscores the elevated HIV prevalence among Kenya’s key populations, estimated to be 29.3% among sex workers, 18.2% among men who have sex with men (MSM) and 18.3% among people who inject drugs (PWID). These levels are 3-5 times greater than the national average (5.6%). The request also places considerable emphasis on new data from the TB prevalence survey, which revealed that about 40% of all TB cases in the country go undiagnosed.
To address these issues, Kenya proposes several innovative interventions. For key populations, HIV self-testing and pre-exposure prophylaxis (PrEP) is included. Tailored packages for young key populations and support for the children of key populations are also prioritized. To improve TB diagnostic capacity, the country proposes innovative synergies with other disease programs. For example, the National TB and Leprosy Program plans to work with the malaria program on the placement of light-emitting diodes (LED) (which will be procured through the malaria program) to phase out light microscopes. It will also seek to procure GeneXpert cartridges in joint partnership with the HIV program.
Additional investments in these areas are contained in the country’s matching funds request. It is important to note that Kenya is eligible for the largest amount of matching funds of any country. This includes $10 million for key populations and $6 million for finding missing TB cases. The country also applied for matching funds for adolescent girls and young women and to remove human rights-related barriers.
The matching funds request focuses heavily on strengthening new and existing national networks of key populations, enabling them to lead the design and delivery of their own programs. This is in line with the latest global normative guidance on implementing comprehensive HIV programs among key populations (the “MSMIT”, “SWIT”, “IDUIT” and “TRANSIT”), which emphasizes the importance of fostering programs led by key populations themselves.
To catalyze TB case finding, Kenya requested matching funds to enable a pay-for-performance approach for motivating health facility management to implement TB case finding activities. Kenya also proposes to establish a County Innovation Challenge Fund for community actors to develop and implement innovations to reach clients with low access to TB care.
Supporting the delivery of the proposed interventions, Kenya’s funding request contains several interventions aimed at building resilient and sustainable systems for health (RSSH). In particular, many of the proposed activities are geared towards strengthening various aspects of the “COMBO” project, a localized investment case approach that enables individual counties to achieve allocative efficiencies in their HIV and TB responses.
Plans to sustain the proposed Global Fund investments are already underway in the country. The forthcoming Kenya Health Financing Strategy (KHFS) is focused on raising domestic resources for health, aiming for 83% of total health expenditure to be pooled from local sources (government plus social insurance) by 2030. Classified as a middle-income country by the World Bank (since October 2014), Kenya must now make extra sustainability assurances to the Global Fund. The funding request heralds the KHFS as a key strategy in this regard.
The need for better sustainability planning in Kenya is clear. “Compared to the country’s last concept note, the allocation for this funding request was drastically reduced,” says Nelson Juma Otwoma, National Coordinator of the National Empowerment Network of People living with HIV/AIDS in Kenya (NEPHAK). “In addition, the government has not been very clear on their contribution,” he said. Otwoma is a member of Kenya’s country coordinating mechanism, representing people living with and affected by the diseases.
The Technical Review Panel (TRP) is expected to meet from 19-28 June 2017 to review funding requests submitted in the May 2017 window. The TRP’s response to Kenya’s funding request is anticipated in early July.