On 23 May 2017, Zambia submitted both TB/HIV and malaria funding requests, together worth just over $400 million. The TB/HIV funding request was for $306.8 million, of which $194.4 million constituted a within-allocation request, with a further $112.4 million as a prioritized above-allocation request (PAAR). A separate funding request for malaria was submitted on the same day for $86.7 million ($69.0 million within-allocation and $17.7 million PAAR). The country also submitted a matching funds request for $7.0 million, of which $4 million was targeted at HIV programs for adolescent girls and young women (AGYW), and $3 million was for integrated service delivery as well as human resources for health. May 2017 is the second window of submission for the 2017-2019 funding cycle.
The country submitted both funding requests for full review, based on the Global Fund’s differentiated application process. The full reviews were necessitated, in part, by a wave of new national strategies. Zambia has a new National HIV and AIDS Strategic Framework (NASF); a new National Strategic Plan for Tuberculosis Prevention, Care and Control; a new National Malaria Elimination Strategic Plan; and a new National Health Strategy. All four new strategies are for the 2017-2021 period.
Among the strategic changes reflected in the funding requests is an increased focus on human resources for health, especially in rural areas and at decentralized levels of care. Between the country’s allocation and the matching funds, more than $20 million is requested to recruit and retain rural-based nurses, community health assistants and adherence support workers. Compared to the country’s current Global Fund grants, this represents a more than five-fold increase in investment in human resources for health. If the PAAR is considered, it becomes a 20-fold increase.
The proposed Global Fund investment in human resources for health in Zambia is intended to complement the considerable domestic investment in health infrastructure in recent years. Since 2014, the government of Zambia has begun construction of more than 650 new health posts (primary care clinics), decentralizing service delivery and bringing access closer to communities. The Global Fund investment in nurses and community health assistants will go towards ensuring that the new government facilities are adequately staffed.
The funding requests include built-in sustainability mechanisms for the proposed human resources investment. In the TB/HIV application, the country commits to absorbing the nurses onto government payroll in a staged approach over the three years. Zambia has a good track record of absorbing health workers following similar investments from other funding partners, including the Clinton Health Access Initiative (CHAI), and the Swedish International Development Cooperation Agency (SIDA), among others.
In addition to the support for rural nurses, the country requested funding for training, deploying and retaining up to 500 community health assistants each year. In Zambia, community health assistants undergo formal training through a year-long course at one of two schools (Ndola or Mwachisompola). When they are deployed, they receive a monthly salary as well as a bicycle, a uniform and a small stipend for transport. The community health assistants are a relatively new cadre of health worker in Zambia, but they have demonstrated significant impact. The rollout of the community health assistants has resulted in a 53% increase in the number of patients being referred to health centers in rural parts of Zambia between 2011 and 2016. The TB/HIV funding request also touts the community health assistants as a sustainable investment, given that the attrition rates of this cadre are extremely low. Only five community health assistants (0.46%) are no longer working since the program began, three of these due to death.
Along with government health workers and community health assistants, Zambia’s funding requests also prioritize significant investment in capacity building for civil society organizations and community groups to deliver services, particularly to key and vulnerable populations. This includes financial management training, as well as trainings in adaptive leadership and governance for youth-focused organizations – particularly those working with AGYW. The need to build the capacity of these groups is linked to an increased emphasis on delivering friendly and competent services to AGYW. In fact, the amount of money requested for AGYW in the country’s proposal represents a more than 30% increase compared to the current grant.
In addition to AGYW-focused organizations, the funding requests also prioritize strengthening the capacity of community structures to deliver inclusive and gender-responsive integrated services to meet the specific needs of other key and vulnerable populations (as defined in the country’s new national disease strategies). The TB/HIV funding request positions this capacity building of civil society and community groups as a critical action towards expanding community-led service delivery to cover at least 30% of all service delivery by 2030 – a key commitment in the 2016 U.N. Political Declaration on HIV and AIDS, to which Zambia is signatory.
“The focus on human resources for health in the Global Fund applications – both in terms of government and non-government service providers – is driven by the country’s new National Health Strategy for 2017-2021,” says Dean Phiri, who is with the Ministry of Health. “Providing quality health care to under-served areas and decentralizing service delivery to communities are key objectives of the strategy,” he said.
Simon Muchiru, the lead consultant for Zambia’s TB/HIV funding request, said that expanding the country’s health workforce is also aligned to the Global Fund’s strategic objective to build resilient and sustainable systems for health. “These investments are a critical backbone to achieving impact against the three diseases,” said Muchiru. “The additional health workers are absolutely vital for full implementation of the NASF, which is expected to avert 80,000 new HIV infections and 34,000 AIDS-related deaths over 2018-2020.”
The Technical Review Panel (TRP) is expected to meet from 19-28 June 2017 to review funding requests submitted in Window 2. The TRP’s response to Zambia’s funding request is anticipated in early July.
Gemma Oberth was part of the writing team for Zambia’s TB/HIV funding request. Her work on the funding request was in her capacity as an independent consultant.