“The funding request demonstrates evidence-based prioritization of key populations affected by both HIV and TB and proposes appropriate high-impact interventions to expand services in high-burden counties as informed by a clear geographical prioritization.”
This was one of the observations of the Technical Review Panel (TRP) when it reviewed the TB/HIV funding request submitted by Kenya. The TRP also mentioned other strengths of the request as well as several weaknesses and concerns. This article summarizes the observations of the TRP and the Grant Approvals Committee (GAC).
On 1 December 2017, the Global Fund Board approved four grants under Kenya’s 2017–2019 allocation, as part of the third batch of approvals (see GFO article). The grants, totaling $313.0 million, emanate from the “full review” TB/HIV funding request submitted by the Kenyan country coordinating mechanism (CCM) in Window 2 on 23 May 2017. The $313.0 million includes $17.5 million in catalytic matching funds. The Board approved $24.8 million in matching funds, but some of this amount has been folded into RSSH interventions in Kenya’s malaria component, which was also approved in December.
Aidspan reported on the content of the TB/HIV funding request in June 2017.
The four grants are managed by three principal recipients (PRs). The National Treasury serves as PR for the majority of the funds, via two grants: KEN-H-TNT ($179.5 million) and KEN-T-TNT ($30.0 million). Although the National Treasury is the PR, the Ministry of Health, as lead sub-recipient, is the implementing agency. The Kenya Red Cross Society manages a $70.7 million HIV-focused grant (KEN-H-KRCS) and the African Medical and Research Foundation is PR for a $32.6 million TB grant (KEN-T-AMREF). The same organizations served as PRs for grants during the 2014–2016 allocation cycle.
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The funding request also included a prioritized above allocation request (PAAR) totaling $140.0 million. The TRP deemed all of the PAAR to be quality demand. During grant-making, two TB modules from the PAAR were integrated into the within-allocation request, and there was some additional shifting of allocation and catalytic funds among the various components. In the end, the total amount added to the Unfunded Quality Demand (UQD) register was $112.8 million.
The funding request was reviewed by the TRP on 30 June 2017 and, following grant-making, was recommended for funding by the GAC in early November. The information in this article is drawn mostly from the TRP’s Funding Request Review and Recommendation Form and the GAC’s Electronic Report to the Board. (These documents are not available on the Global Fund’s website.)
The TRP praised the quality and technical sophistication of the funding request. It said that the programs described in the request aim to increase HIV prevention and care program coverage for men who have sex with men (MSM) (+130% in the amount invested over three years), and to expand services for sex workers (+80% invested), as well as to strengthen programs for people who inject drugs. These key population prevention modules accounted for 6% of the total HIV budget in the funding request. (Six percent may not seem like a lot, but the grant is heavily commoditized –– more on this below –– so there was not much room for discretionary spending.)
The TB component included specific interventions for TB key populations — namely refugees, prisoners, displaced people, migrants, ethnic minorities, miners, children, urban poor and the elderly — as well as the above-mentioned HIV key populations.
The TRP applauded the funding request for its “detailed and honest appraisal” of challenges and program gaps, particularly regarding human rights barriers; and it considered the activities designed to reduce those barriers to be “commendable.” The CCM’s analysis of the funding landscape was also praised by the TRP.
The GAC highlighted that the funding request was responsive to a 2016 TB prevalence survey which revealed that up to 40% of TB cases in Kenya remained undetected. The funding request proposed several new approaches to address the TB epidemic, which is larger than previously believed. These new interventions include enhanced proactive case detection initiatives, optimization of GeneXpert machines, and scaling up of sputum transportation and X-ray use.
Concerns and weaknesses
On the Review and Recommendation Form, the TRP specified 10 areas of concern, gaps and weaknesses in the funding request. For each issue, the TRP made a recommendation on how the issue might be addressed during grant-making or grant implementation. A selection of these issues is highlighted below.
One concern was the case of 220 health workers (clinical officers, lab technicians and specialists, and data management assistants) and a number of National Treasury staff whose salaries and incentives will be paid with grant funds, but for whom there was no explicit plan for the Government of Kenya to eventually take on their salaries. The TRP viewed this as an issue of sustainability, and it recommended that the CCM and the country team develop a human resources for health transition plan during the course of grant-making and implementation. The Kenya CCM has since committed to developing a personnel “exit plan” during grant implementation.
A weakness identified in the funding request related to insufficient description of strategies to improve antiretroviral treatment (ART) retention. The funding request noted declining rates of treatment retention over time but did not describe how the program would address this challenge. Given that improved treatment retention and outcomes are critical impact indicators, the TRP recommended that, during grant-making, the CCM strengthen its approach to achieving better outcomes on the HIV care cascade regarding the 90-90-90 targets. According to the Secretariat, this issue was addressed during grant-making by the CCM providing additional explanations concerning how planned interventions will contribute to achieving the 90-90-90 targets.
Noting that “adolescents and youth are the key drivers of Kenya’s HIV epidemic with more than 50% of new HIV infections occurring among young people,” the TRP expressed concern that the funding request only included a small allocation for HIV prevention for young people. The TRP described the budget for youth HIV prevention as a “significant[ly] disproportionate allocation,” and encouraged Kenya to carefully consider its HIV prevention priorities as the modules and interventions are finalized during grant-making. This issue was also addressed to the country team’s satisfaction.
The funding request included interventions for expanding TB case-finding in the private health care sector, where many TB cases elude identification and registration with national TB control systems. The TRP supported this approach but recommended that the Kenyan program expand private sector engagement to include HIV services in addition to TB. Specific mechanisms for this expansion, however, were not detailed in the TRP feedback. This issue was marked “addressed,” in grant documents, but there was no explanation regarding how it was resolved.
In its recommendation to the Board, the GAC highlighted that despite progress and plans for continued ARV coverage scale-up, “available resources from the 2017–2019 allocation are under extreme pressure.” The GAC noted that secured resources appeared to be sufficient to continue ART for the 1.1 million people currently receiving treatment, but that adding more patients would be challenging. A $65.0 million ART funding gap was identified and registered as UQD. Based on this calculation, the GAC recommended that the Global Fund Secretariat and partners “intensify their engagement and collaboration with the country to explore ways to address the financing gap.” Aidspan recently reported on this emergent challenge in Kenya and across the Global Fund portfolio.
It appears there won’t be an easy fix here, given that the Government of Kenya has already committed $966.0 million towards HIV programs during the 2017–2019 allocation cycle, an increase of $123.0 million over the previous period. These contributions more than satisfy Kenya’s co-financing requirement which was $71.1 million, 20% of the total allocation. Domestic funds are primarily used to procure key commodities such as ARV and TB drugs. See the table below for more details on the HIV funding landscape.
Table: Overview of funding landscape ($ million)
|Component: Kenya HIV|
|Estimated funding need
As % of
|Change vs. previous period|
|Total domestic resources||966 m||26%||Increase|
|Total external resources (non-GF)||1,719 m||46%||Increase|
|Total Global Fund resources||231 m||7%||Decrease|
|Total resources available||2,916 m||79%||Increase|
|Unmet need gap||791 m||21%||Decrease|
(We note, in passing, that Kenya’s co-financing requirement, at 20% of the allocation, is five percentage points higher than the minimum required under the Sustainability, Transition and Co-Financing Policy. For lower-middle-income countries like Kenya, the policy states that the co-financing requirement must be at least 15% of the allocation. But the Secretariat has the discretion to increase the percentage in individual cases.)
Both the TRP and the GAC noted the complications for grant oversight caused by devolution in Kenya. Devolution is the process of decentralizing state power throughout the country, most notably from the national government to county governments. In Kenya, devolution has been underway since the new constitution was promulgated in 2010. The GAC considered devolution to be an opportunity to be fully exploited, but one which comes with the need to implement appropriate financial and programmatic safeguards. The National Treasury, the Ministry of Health and the Council of Governors (COG) are currently engaged in a consultative process whereby best practices for funds flow and financial oversight between the national and county levels are being reviewed. According to the GAC, a report of the findings of this process will be presented (timeline unknown), and an operationalization roadmap will be developed and implemented by the PRs, the National Treasury and other stakeholders.
The COG is a non-partisan organization comprised of the governors of each of Kenya’s 47 counties. According to the website of the Government of Kenya, the COG provides a forum for discussion of issues relevant to county government and for the promotion of best practices. The GAC noted that counties, through the GOC, have become much more active in Global Fund processes. For example, the GAC said, the COG has seats on the CCM and was represented on the writing team for the funding request.