In its review of Uganda’s TB/HIV funding request, the Technical Review Panel (TRP) praised the country for positioning the request as part of a more sustainable response, including a push to improve coordination with the private sector, and for scaling up interventions for key populations.
The TRP also responded favorably to the proposal’s alignment with the country’s national strategic plans for both diseases, though the TRP highlighted some concerns, particularly around a lack of clarity within TB programming.
(Some of the information for this article came from the Grant Review and Recommendation Form, a copy of which was obtained by Aidspan.)
The Global Fund Board approved two grants worth $278.4 million emanating from the funding request. Most of the funding is for HIV programs; fewer than 12% of the funds are dedicated to TB or joint TB/HIV programming. Uganda also requested an additional $263.6 million in its prioritized above-allocation request (PAAR). The TRP deemed all of this amount to constitute “quality demand.”
However, two requests for matching funds totaling $9.4 million were recommended for further iteration. Uganda had requested $5.0 million for programs to remove human rights-related barriers to health services and $4.4 million for programs for HIV services for adolescent girls and women.
Strengths of the funding request
In its assessment, the TRP called the request “technically sound and strategically focused,” reflecting a comprehensive situational analysis based on the most recently available epidemiological data. The TRP said the proposal “identified the right critical gaps in programming.”
The TRP said that Uganda’s proposed AIDS Trust Fund allocation from taxes is a creditable move towards sustainability for the HIV response. The TRP also praised the fact that Uganda is increasing the allocation in its budget for commodities. In addition, the TRP applauded the pledge to engage technical and political leadership to advocate for increased resources and appropriate legislation. The TRP said that the funding request included a description of “new and important approaches” to build political commitment for the fight against HIV and TB.
The TRP also said the proposal called for Global Fund money to be utilized “in alignment with other country investments to minimize duplication,” specifically with respect to PEPFAR funding.
In its review, the TRP was also encouraged by the fact that the funding request addressed issues raised in Uganda’s previous TB/HIV concept note regarding specific efforts to reach key and vulnerable populations, including paying particular attention to the enabling environment and the strengthening of condom programming. Finally, the TRP noted that the funding request included several interventions aimed at removing structural and legal barriers to key and vulnerable populations accessing services.
The TRP identified some weaknesses that it said needed to be addressed. Most of them were related to the TB portion of the proposal.
The TRP identified two issues regarding TB screening of people living with HIV. The TRP said it was not clear whether Uganda was prioritizing having people living with HIV enter HIV care and receive antiretrovirals (ARVs) within the first 3-6 months after diagnosis when TB incidence is highest. In addition, the TRP said that although the funding request indicated that Uganda plans to undertake systematic screening of vulnerable groups, the applicant did not describe the approaches or the screening and testing algorithms that will be used.
These issues were at least partially addressed during grant-making. The applicant indicated that for HIV-infected persons in care, TB screening, using a symptom assessment, will be carried out at each clinic visit, with the addition of a chest x-ray for new patients enrolling into the ARV treatment program and those who have been on ARVs for less than six months. The review and recommendation form did not indicate whether the issue concerning vulnerable groups was addressed.
The TRP said that while Uganda had identified poor treatment outcomes as a major challenge, it did not provide enough information on what caused these outcomes. Consequently, the TRP said, “the proposed solutions are generic in nature.” This issue was also discussed during grant-making. The TRP said that it was satisfied with Uganda’s plan to test various hypotheses in a program-based research project. The TRP describe this research as “critical,” and recommended that should additional funds become available, they be used to help fund this study.
The TRP noted that although the funding request identified gaps in the National TB Program’s workforce, it did not provide an analysis of the nature of the gaps, and it did not include a plan to address the gaps in a sustainable way. These issues, too, were addressed during grant-making. The TRP said it was satisfied with the applicant’s response, but the review and recommendation form did not describe the response. However, the form reflected the TRP’s concern that the TB program’s human resources seem to be heavily dependent on external resources, which, the TRP said, may jeopardize sustainability of the program in the long run. The TRP said that it is of particular concern that many of the key positions are supported by USAID and dependent on the continuity of financial support from this source.
The TRP recommended that the Secretariat follow closely the workforce situation and that the applicant develop and implement a sustainability plan to ensure absorption of key positions by the Ministry of Health.
Concerning the HIV response, the TRP said that the targets for retaining people living with HIV on antiretroviral treatment were not ambitious enough. The baseline was 80.3% and the request set a target of only 84.5% in the third year of the grant. Furthermore, the TRP said, the baseline for viral load suppression among the people who access viral load testing was 91.3%, but the proposed targets in the funding request for Years 1, 2 and 3, respectively, were 70%, 80% and 90%, implying a decline in efforts to support adherence. The TRP requested that Uganda anticipate the challenges associated with scale-up and develop strategies to maintain or increase viral load suppression rates and to improve retention rates. This issue was to have been addressed in grant-making, but the review and recommendation form did not indicate what the outcome was.
Efficiencies, PAAR and matching funds
During grant-making, $411,000 in efficiencies were identified, primarily from the rationalization of training and supervision costs. The savings were reinvested in the grants to fund the roll-out of differentiated service delivery models.
Of the eight interventions in the PAAR, the TRP rated two as high priority, four as medium and two as low. The highly rated interventions were to improve detection and treatment of drug-resistant TB and to increase condom programming and distribution. The PAAR request amounted to $263.6 million. After adjusting for the reinvested savings, interventions worth $263.2 million were added to the Unfunded Quality Demand (UQD) Register.
Concerning the requests for matching funds, the TRP determined the two requests were not “robust enough.” The TRP said it expected that the $5.0 million request to remove human rights-related barriers to health services would focus on high-priority interventions clustered around programs recommended by UNAIDS to address stigma and discrimination and increase access to justice. Instead, the TRP observed, most of the proposed activities were service-oriented, aimed at expanding prevention activities.
The TRP said that the matching funds for programs for adolescent girls and women were meant to increase programmatic targets and coverage and to improve program quality. The TRP said that the money should be used to support a few interventions, which can be carefully monitored for impact. However, the TRP added, Uganda's $4.4 million request was for a large number of activities, many of which already exist, and the expected outcomes were not quantified.
The TRP requested that Uganda resubmit matching funds requests that draw a clearer link between the activities funded under the main allocation and the complementary activities to be paid for with the matching funds.
Despite increasing domestic contributions, Uganda’s health sector – and especially programs responding to HIV, TB and malaria – are heavily donor dependent. However, the review form noted that a number of steps have been taken or are being implemented to mitigate this overwhelming dependence. These steps include the introduction of a government health financing strategy, the creation and maintenance of a budget line for drugs to treat the three illnesses, the establishment of an AIDS Trust Fund (mentioned above), and additional investments in the health system.
Ultimately, the Ugandan government committed enough additional funding to meet the Global Fund’s co-financing requirements.