Among the grants approved by the Board in the third batch of funding (see GFO article) were four TB/HIV grants to Mozambique. In this article, we report on the comments of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) on the funding request from which these grants emanated.
Mozambique has a population of 27 million people with an estimated HIV prevalence of 13.0% among people aged 15–49. The number of people living with HIV (PLHIV) is estimated to be 1.9 million. Its HIV treatment program has quadrupled between 2010 and 2016, increasing antiretroviral treatment (ART) coverage to 54.0% with a retention rate of 70.0%. Estimated TB incidence in Mozambique is 551 per 100,000 people, with a TB notification rate of 278 per 100,000 people. The TB notification rate has increased by 17.2% since 2015. HIV prevalence among TB patients tested for HIV has declined from 64.0% in 2010 to 44.0% in 2016.
The TRP said that the request for funding was aligned to the priorities identified in Mozambique’s national AIDS and TB strategic plans as well as its National Strategy for Health. The request demonstrated a clear commitment to achieving the UNAIDS 90-90-90 strategy, building on recent progress in increasing ART initiation.
The TRP welcomed the strong focus and increased targets for HIV testing in the funding request. In 2016, thanks to Mozambique’s “one stop model,” 96% of TB patients know their HIV status and 94% of co-infected patients were initiated on ART.
The Board approved $347.0 million, including matching funds of $11.9 million. The TRP deemed all of Mozambique’s $141.9 million Prioritized Above Allocation Request (PAAR) to be “quality demand.” Savings of $6.6 million found during grant-making were reinvested in some of the PAAR initiatives. The remaining interventions, totaling $135.3 million, were added to the Unfunded Quality Demand (UQD) register.
The program will be implemented by four principal recipients (PRs) as per the table below.
Table: Approved grants to Mozambique ($US million)
|Comp.||Grant name||Principal recipient||Budget ceiling|
|TB/HIV||MOZ-C-CCS||Centro de Colaboração em Saúde||27.9 m|
|HIV||MOZ-H-FDC||Fundação para Desenvolvimento de Commudidade||27.9 m|
|HIV||MOZ-H-MOH||Ministry of Health||249.4 m|
|TB||MOZ-T-MOH||Ministry of Health||41.9 m|
The implementation period for the grants is 1 January 2018 to 31 December 2020.
A differentiated HIV testing and counselling approach, simplifying and adapting HIV services to reflect the preferences and expectations of different key populations living with HIV –– e.g. sex workers, adolescent girls and young women (AGYW) and men who have sex with men (MSM) –– will be a central focus of the new grants. Through the differentiation approach, the prevention component of the HIV program aims to reach roughly 1.2 million AGYW, 6,000 MSM and 64,000 sex workers with comprehensive HIV packages by 2020.
Strengths of the funding request
Overall, the TRP said that the main strength of the request for funding was that it was technically sound and strategically aligned to Mozambique’s national strategies and plans. The activities in the funding request speak directly to the epidemiological situation of both TB and HIV in Mozambique and have a strong focus on targeting key populations with prevention interventions, the TRP said. The funding request included the expansion of HIV services from 19 to 84 prisons, which, the TRP noted will increase access to an underserved key population. Furthermore, the request was developed with the full participation of civil society, including key population representatives. Two new civil society PRs have been added, signaling an “increase in engagement,” said the TRP.
Mozambique’s funding request had a strong focus on ART retention and adherence for people who were recently initiated on ART, the TRP noted. The target for the new grant is to increase the 12-month retention rate for ART from 54% to 80%, an ambitious target to ensure attainment of the UNAIDS 90-90-90 strategy, the TRP stated.
Finally, the TRP said that the funding request described the health system situation in Mozambique in a “crisp manner,” and that the use of health system analysis diagrams demonstrated a clear understanding of the impact of health system gaps and bottlenecks on the national HIV and TB responses.
Issues and recommendations
The TRP identified several issues that it said should be addressed during grant making and/or grant implementation. The grant documentation indicated that all of the issues were satisfactorily addressed during grant making, but no explanation of how they were addressed was provided.
Below is a description of some of the issues as well as the recommended actions by the TRP to address them.
HIV interventions for key populations. HIV interventions targeting key populations did not show the geographical location of where they will be implemented, nor did they describe how these investments complement partner investments (e.g. PEPFAR). The TRP requested that the CCM develop a matrix to map out the locations of current interventions using available population size estimates and geographical coverage to facilitate the prioritization and synergies of interventions among the various donor investments.
The coverage and targets for comprehensive prevention services for key populations over the 3-year grant period were low and the lack of a policy and operational framework for people who inject drugs is likely to negatively affect implementation of harm reduction interventions. The TRP requested the CCM to work closely with the Secretariat and other partners to identify new program approaches to increase the geographical coverage of comprehensive prevention services for MSM and female sex workers. Furthermore, the TRP recommended that the CCM work with the Ministry of Health to develop a rights-based policy guideline for harm reduction, which should include practical steps on how to overcome legal barriers that hinder access to harm reduction services.
Treatment retention. The funding request lacked clear strategies of how Mozambique is planning to improve treatment retention for people on ART. The TRP asked the CCM to develop a plan with clear guidelines of service packages to be delivered at the community level to facilitate the retention of newly enrolled patients as well as those already on treatment.
MDR-TB outcomes. The poor treatment outcomes for MDR-TB was a cause for “serious concern” for the TRP. It said that the interventions included in the funding request to improve treatment outcomes were not clearly articulated. The TRP recommended that the CCM (a) increase the targets for MDR-TB treatment success rates to ensure there is no pre-treatment loss to follow-up; and (b) develop a brief operational plan for improved MDR-TB outcomes that defines the interventions to improve care. The TRP said that the plan should also describe how all confirmed MDR-TB cases will be enrolled and supported to adhere to treatment.
Awareness campaigns. The TRP said that it did not believe the proposed awareness campaigns to be financed by the matching funds award and the corresponding funds from Mozambique’s allocation would yield many additional cases or facilitate the diagnosis of missed cases. In addition, it said, the funding request did not sufficiently describe the implementation of the FAST strategy (finding actively TB and MDR-TB cases, separating safely, and treating effectively) or demonstrate how it will improve TB case finding. The TRP recommended that the CCM work with the Secretariat to reassign awareness campaign funds to direct service delivery for case detection and management.
Three initiatives were added to the UQD register, as follows:
- expanding differentiated ART programs for PLHIV to reduce AIDS-related mortality and HIV incidence by 40% by 2020;
- integrating service delivery for TB and HIV through the resilient and sustainable systems for health (RSSH) by addressing critical gaps and risks to program implementation; and
- nutritional support for 70,000 PLHIV on ART who are currently suffering from acute malnutrition, to complement 50,000 already receiving PEPFAR support.
Mozambique was awarded matching funds covering four strategic priority areas. Two were HIV-related –– removing human rights–related barriers to health services ($4.7 million); and programs targeting AGYW ($6.0 million). One was TB-related: finding missing TB cases ($6.0 million). The last one was related to RSSH: data systems, data generation and data use ($3.0 million). Mozambique was awarded these funds on the condition that it come up with matching amounts for each strategic priority area from its 2017–2019 allocation. Two of the matching funds requests –– the one on AGYW and the one on finding TB cases –– were submitted as part of the overall funding request. According to grant documents, at the time of grant-making the other two requests had not yet been submitted.
For the two matching funds requests submitted, the TRP found that only parts of them were technically sound. Both requests were sent back for iteration for the following reasons:
Finding missing TB cases. The CCM proposed three interventions: (a) screening of household and workplace contacts in five high-burden provinces; (b) media awareness campaigns; and (c) stakeholder engagement. The TRP considered the last two to be low impact and poor value for money, and so it recommended proceeding with only the first intervention. The TRP recommended that this intervention be further refined in order to “pay careful attention to activities around addressing missing TB and MDR-TB cases.”
HIV prevention for AGYW. The proposal identified three strategic priority areas: (a) a training drive for health service providers and lay cadres; (b) socioeconomic interventions to keep girls in school; and (c) HIV testing services for adolescents and youth. The TRP said that the proposed activities were sound, but that the CCM had not provided enough information on how they would complement other interventions from the within-allocation funding request. In addition, the TRP requested that when the CCM resubmits this request, it include clearer details of program scale and coverage, especially relating to high priority geographical areas.
Co-financing and domestic contributions
The co-financing requirement for Mozambique for 2017–2019 is $13 million each year. The government had provided a letter committing to invest $25 million annually. However, the Secretariat believes there is a considerable risk that Mozambique won’t be able to meet its commitment given the significant fiscal challenges the country is facing. The impact of severe depreciation of the Mozambican metical (by 107% in the last two years) has led to a substantial increase in debt, mostly denominated in foreign currency. Therefore, to mitigate this risk, the Global Fund has included a specific condition in the grant confirmation that requires that at the end of each calendar year, the government will provide evidence that its commitment has been met. The country team will monitor the fulfilment of the condition by reviewing the annual reporting of government spending on HIV, TB, malaria and RSSH.
A key outstanding issue, which will be tackled during grant making, is the long-term sustainability of TB and HIV programming in Mozambique. In fact, HIV and TB will be 90% funded by external resources in the 2018–2020 implementation period of the grants, making the current sustainability outlook seem weak. In addition, the projected domestic commitment to the HIV and TB budget is minimal, 4% and 3% respectively for the 2018–2020 implementation period. Considering that in the 2001 Abuja Declaration, African countries committed to dedicating at least 15% of the overall government budget to health, Mozambique has a long way to go to meet the commitment.
Mozambique is currently developing a health financing strategy which is expected to be completed at the end of 2017. In addition, Global Fund support during the implementation period of the new grants will be used to kick-start the process of decentralizing the public finance management system to provincial and district levels with the aim of improving value for money.