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Global Fund Observer


Issue 244: 28 May 2014

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1. COMMENTARY: Transition to the NFM marred by unanticipated consequences

Achieving the launch of the new funding model was no small accomplishment. It is unfortunate, says David Garmaise, that the transition from the rounds-based system has added complications and has had some unanticipated consequences. 

2. COMMENTARY: New funding model: a modern approach

In a rebuttal to a commentary by David Garmaise, the Global Fund says the new funding model (NFM) is designed to optimize use of all available funding, from all sources, so that partners can work together to find the most effective solutions to health challenges. The Global Fund is challenging what it says is Garmaise's seeming interest in the Global Fund's preservation of historical operating methods. But everything changes, especially the reality of HIV, TB and malaria. The new funding model was set up to adjust to change, not to block it. 

3. NEWS: Kenyan concerns about rising MDR-TB reflect regional public health challenge

Heightened microbial resistance is threatening the progress Kenya has made in its fight against tuberculosis. That the majority of the multi-drug resistant TB cases are among refugees -- most of them Somali -- underscores the need for a regional approach to the disease in East Africa and better integration with HIV programs.

4. NEWS: Recognition of India’s third gender could boost Global Fund-supported programs for sexual minorities

A ruling by India's Supreme Court recognizing transgender people as a third sex could help improve the impact of Global Fund- supported programming targeting sexual minorities.

5. NEWS: Djibouti seeking no-cost extension of HIV grant

The tiny Horn of Africa nation of Djibouti is anticipating obstacles in its preparation of an integrated HIV/TB proposal to access its allocation under the Global Fund's new funding model, due to limited technical capacity.

6. NEWS: New funding model in Latin America yields new partnerships -- and new expectations

Government decision-makers from across Latin America joined civil society stakeholders in Quito, Ecuador in April to plot a regional way forward under the Global Fund's new funding model.

7. REVIEW: Five key recommendations from ICASO for civil society in Global Fund country dialogue

A review of a new guidance note from ICASO to help civil society organizations and groups representing key affected populations navigate the Global Fund's country dialogue process unpacks five key recommendations to ensure that these traditionally marginalized stakeholders find their voice and their place at the table during the process.


1. COMMENTARY: Transition to the NFM marred by unanticipated consequences

David Garmaise 28 May 2014

The letters sent on 12 March to the 123 countries eligible for Global Fund grants should have been heralded in Geneva with trumpets and the popping of champagne corks.

These letters, signed by Grants Management chief Mark Eldon Edington, represented two years of painstaking work to develop the new funding model (NFM): a new way of working for the Fund that aims to shift the focus towards high-impact, high-value programs in countries with the highest burdens of disease and the least ability to pay, and which sets out to achieve better programming, improve results and “do more with less.”

But instead of celebrating, there appears to be some grumbling at the country level, especially about how the transition was communicated. Decisions concerning the transition from the rounds-based system to the NFM have, perhaps inevitably, bred uncertainty and, I believe, have had unanticipated consequences (see below).

As the NFM was being designed, the perception was that the allocations methodology would apply only to new funding available for new grants. The numerous calculations – from the application of the income/burden formula to the graduated reductions for over-allocated countries – seemed designed specifically for new money: funding that would come from the Fourth Replenishment and that would be available for new grants.

It appeared, to me at least, that existing grants would run their course (under the “old rules”) and that the 2014–2016 allocations would be derived entirely from new funding.

Obviously, this was a misconception.

At its meeting in November 2012, the Global Fund Board decided that the allocations to country bands would take “both committed and uncommitted assets into account”. This was interpreted to mean that the allocations for 2014–2016 would include both funding for existing grants and additional funding for new grants. But neither the Board nor the Secretariat seemed to know exactly how it would work. Issues concerning the transition from rounds-based funding were discussed in some depth in the Board committees and in the Secretariat, but could not be made public until the Board formally adopted the transition provisions in March 2014.

Part of the problem was the size of the existing grants pipeline at 31 December 2013: $9.06 billion. The money on hand to pay for these grants was only $5.55 billion. This left a gap of $3.51 billion which had to come from the $10.22 billion raised in the Fourth Replenishment. This left $6.71 billion for new grants ($5.76 billion in base funding and $0.95 billion in incentive funding).

In previous replenishments, it was common practice to use some of the funds raised to pay for grants previously approved. However, the size of the existing grants pipeline, which was influenced by two very large rounds of funding (Rounds 8 and 9), surprised a lot of people.

We, at Aidspan, ought to have been asking questions about the implications of the existing grants pipeline well before the NFM was formally launched.

Unanticipated consequences

In my opinion, the decision to combine existing and new funding in the allocations has had several unanticipated consequences:

  1. Some components are receiving no funding for new grants.

  2. Application of the global disease split to the total base funding available ($14.82 billion) has created distortions in the allocations.

  3. The new willingness to pay (WTP) requirements are being applied to components that are receiving no funding for new grants.

Some components getting no funding for new grants

By allocating some components only enough money to cover the costs of existing grants, the Global Fund is, in effect, re-balancing its portfolio retroactively using existing funding. Whether this is fair is debatable. What does “fair” mean in this context?

On the one hand, components that are receiving only enough money to cover existing grants are those that were getting way more than their fair share in recent years. From that perspective, maybe allocating these components no money for new grants is fair.

On the other hand, one could argue that the existing grants stem from past commitments that the Fund should honor and that the Fund should even allocate some new funding to these components, even if it is significantly less than the components had been receiving. Indeed, the graduated reduction provisions of the NFM were designed to do exactly that.

Global disease split: distortions

The global disease split is important because it is one of the first steps in the allocation methodology. The split is used to create three disease envelopes, and the envelopes then form the basis for calculating the allocation for each disease component to each country.

The global disease split was decided by the Board (50% HIV, 32% malaria; 18% TB). It resembles, but is not identical to, the historical disease split. The problem is that when the Global Fund applied the 50:32:18 split to the total base funding of $14.82 billion, it was applying it not only to new base funding available for new grants ($5.76 billion), but also to that portion of the funding reserved for existing grants ($9.06 billion).

But the existing grants already had a disease split. The grants had already been awarded. The split is whatever it is. (Precisely what it is, we don't know.) So once again, the Fund is retroactively applying to existing funding a formula designed for new funding. The result is that the disease split provided to countries is distorted. Surely that was not the intent when the methodology was designed?

Willingness to pay

The WTP provisions are being applied to the total base funding of $14.82 billion. Under the WTP, 15% of a component’s base allocation is held back unless the government invests more in its disease programs – more, that is, than what the government is already investing under the counterpart financing requirements. How much more is to be decided during the country dialogue.

To apply the WTP provisions to new funding for new grants is logical. But what about those components that are receiving only enough funding to cover existing grants? To ask governments to make additional investments just to get the money for already-approved existing grants is dubious policy. Yet this is exactly what is happening.

Uncertainty, muddle and a lack of communication

Whether or not the move to allocate some components only enough money to cover existing grants was fair, it certainly was not anticipated. There was no public announcement and no discussion at Board level. Aidspan first learned about this when the allocation letters went out. 

Neither the Board nor the Secretariat has said anything about the other unanticipated consequences of the way in which existing and new funding were combined in the allocations.

In addition, the decision regarding how existing and new funding were combined appears to have implications for how existing grants are handled under the NFM. The Global Fund has not explained publicly what those implications are.

What flexibilities do country have? Can they let their existing grants run their course and only then submit a concept note covering the additional funding they have been awarded? This does not seem to be the option favored by the Global Fund. Some countries have been told verbally that they must submit concept notes as soon as possible. Doing so would require considerable re-programming of existing grants.

Are all countries in a position to go this route? What about a country that is deemed to be over-allocated, that received only enough money to cover existing grants, and that has made considerable formal commitments for commodity purchases. How much flexibility does this country have to re-program?

Countries that are persuaded to re-program their existing grants may conclude that they have essentially “lost” part of their existing grants in the process.

Clearly countries require different approaches. And, to be fair to the Global Fund, the process for handling existing grants is evolving, just as the design of the NFM as a whole is still evolving. The Secretariat has been talking one-on-one with countries. I would welcome a more public explanation of what strategy the Global Fund is pursuing with respect to existing grants.

I would also welcome an explanation of the “four-year periods” we hear about. The decision on transition provisions taken at the last Board meeting said: “While each disease component’s portion of the Total Allocation will typically cover a period of four years starting from 1 January 2014…”

It is not clear to me what that means. And it appears that my confusion is also echoed at the country level. The allocation letters say nothing about a four-year period. I would welcome more information on this issue and on the other issues raised in this commentary. 

As is Aidspan's practice, we shared this commentary with the Global Fund. Their response is the next article in this week's GFO.

[This article was first posted on GFO Live on 28 May 2014.]

To comment on this article, click here.



2. COMMENTARY: New funding model: a modern approach

Mark Eldon Edington and Seth Faison 28 May 2014

David Garmaise opens his commentary with an accurate observation: He had a misperception. But he arrives at a conclusion that is wrong. The consequences of the new funding model were not, in fact, unanticipated.

The most important point is that the new funding model is designed to optimize use of all available funding, from all sources, so that partners can work together to find the most effective solutions to health challenges. Mr. Garmaise asks about the implications of how existing grants are handled under the new funding model. We encourage all countries to reprogram grants where it makes sense. We said so in the opening sentence of a news item we issued when we announced the allocations on 12 March. In his commentary, he ignores that message, and seems to want the Global Fund to preserve the operating methods that he is accustomed to analyzing. But everything changes, especially the reality of HIV, TB and malaria. The new funding model was set up to adjust to change, not to block it. 

In devising the new funding model, the Global Fund had to factor in material and human considerations, like finite resources and a need for a sensible weighing of competing factors. We had to consider all operating procedures in the shift from a rounds-based system to an allocation system, and we also had to work with decisions and compromises made by the Board along the way. It has been quite a challenge. Yet where we ended up was a broad consensus that we have to be looking all resources, including reprogramming existing resources, as the best way to deliver increased impact.

The Global Fund looked carefully at whether to keep ‘existing’ and ‘new’ funding separate. We concluded that it would have been even more complex, and deeply counterproductive, to carry out two parallel systems, with one standard for existing grants and another standard for grants coming from new funding. As the commentary notes, the groundwork for that decision was approved by the Board in 2012, and at that time, the Board’s Strategy Committee and Global Fund staff had not yet figured out how to best implement it. But we mapped a path forward, with a great deal of consultation and hard work.

All major strategic decisions on the new funding model were made by the Board, with the Board’s SIIC and FOPC guiding the staff on what was needed and what was possible. There were extensive discussions around how to address the transition from the rounds-based system to the allocation-based methodology. These discussions were complex, and were held with senior management, Board Committees and the Board over the past two years, and intensely over the past year. The staff of the Global Fund played a big role in exploring all possibilities, and presenting them for Board consideration. That was true for all key financial decisions, including allocation and disease split. Each decision was carefully made, with extensive deliberation. Not everything came out perfectly, but we emerged with a strong consensus that the new funding model had to be set up to encourage optimized use of all available funding, from all sources, aligned with our partnership approach.

The consequences cited in the commentary were anticipated by the Global Fund. It was obvious, and not unanticipated, that some countries would not be allocated additional funds. Portfolio analysis and the country allocations were reviewed one by one.  The consequences were well understood in advance of the allocation announcement – but it doesn’t mean the decisions were easy. What makes most sense to the Global Fund is that it is a country decision how to use all the funds they have been allocated. They all know about the flexibility to combine existing with new funds or to plan sequential grants, discussed extensively with countries. 

Applying willingness-to-pay provisions on all funds was similarly an intended, not an unintended, consequence. We are deliberately sending a very strong message that we are taking counterpart financing very seriously. In countries where the percentage of additional funds is low for a disease component, there is flexibility, and this was pointed out in the allocation letters for the relevant countries.

Disease split is part of managing the global portfolio. There was no distortion in the allocation due to applying the disease split to the total base – it’s consistent with the intent of having a global disease split starting point. But the split in the allocation letters is a guide and not final. Allocation is for a country as a whole. Countries manage their own disease splits.

The four-year issue is tricky. By deciding to mobilize all resources, we realized that funding for countries needs to last until the next replenishment. Practically speaking, from the time of the allocation, it will take many countries until the end of 2014 before a concept note is completed, adjusted, approved and then new grants are signed. Grant periods are normally three years. There is flexibility in the implementation period, meaning the start date and end date, but the vast majority of grants will last three years. As a result, many grants will actually be implemented in a time frame that stretches into 2017. When we first spoke about a “four-year” period, some implementers got understandably (but inaccurately) concerned that we were trying to turn three-year grants into four year grants, which is not true. Instead, because the transition is taking into account existing funds as of January 2014, the year 2014 represents additional time, when CCMs are developing concept notes. So we decided to refer to it as part of the “implementation periods” even though we are talking about grants that will run from 2015 through 2017 for most implementers.

We will not pretend that evolving the funding model has been easy. One of the original desires of the Board was to simplify the overall process. But the combination of financial, logistical, practical, political, timing, historical, and equity factors made that hard. It remains complex, and shifting from one system to another is even more complex. Looking back, we could have been more explicit that “taking existing funds into account” could result in components not receiving new funds in the allocation. There are plenty of things we might have done sooner. Overall, we are implementing the new funding model with a broad consensus that we have the right approach for these times, working in partnership with all our stakeholders.

Mark Eldon Edington is the head of Grant Management at the Global Fund Secretariat. Seth Faison is the head of Communications at the Global Fund Secretariat. The views contained within this commentary reflect the position of the Global Fund. 

[This article was first posted on GFO Live on 28 May 2014.]

To comment on this article, click here.



3. NEWS: Kenyan concerns about rising MDR-TB reflect regional public health challenge

Stéphanie Braquehais 28 May 2014

As regional leader in TB treatment, Kenya is the top destination for those escaping violence, or a lack of diagnostic ability and drugs

Kenya has made enormous strides in its efforts to tackle tuberculosis amongst its population, improving diagnosis and treatment to such an extent that prevalence has dropped from 335 to 299 cases per 100,000 people between 2006 and 2012. But the continuing insecurity in the region backed by the weakness of the health infrastructure in neighboring countries have maintained the flow of refugees into Kenya, and into the national health system in search of treatment and care.

Multi-drug resistant TB (MDR-TB) is of particular concern. Those who flee their homes can at times carry only the clothes on their backs -- not the drugs they need to continue or complete a treatment regimen. Of the 550 patients currently being treated for MDR-TB in Kenya, 87 (15%) are in Dadaab on Kenya’s  eastern border with Somalia: the world's largest refugee settlement, home to more than 500,000 people.

Kenya has achieved a drop in new cases of TB due to detection rates that exceed WHO’s target of 70%, according to Dr Jackson Kioko, director of the TB unit of the Ministry of Health. This success, however, belies the eight new cases of MDR-TB recorded each month in Dadaab, says his colleague, Dr Maurene Kamene.

"In a country that has been at war for more than 20 years, the population is always on the move," Kamene said. "There is no quality control for TB medications, and furthermore, many have begun treatments that they did not finish; this has created a lot of resistance."

Some $32 million was approved in January by the Board of the Global Fund -- which has shouldered much of the financial burden for TB treatment in Somalia -- to, among other things, initiate the roll-out of treatment for MDR-TB to begin to address the disease prevalence of 5.2% among new cases and 40.7% among retreatment cases (see article here).

But while the Somali population is moving across the border into Kenya, the funds are not, which Dr Bernard Langat, in charge of planning policy and research at the National TB , Leprosy and Lung Disease Unit at the Ministry of Health said will place undue strain on its health system and its budget.

"It's adding a burden to our Kenyan situation," added Dr Kioko. "The quantification of medication is based on the Kenyan population, not on the refugees figures."

And while Global Fund resources are paying 89% of the budget for Somalia's TB response, the proportion is significantly smaller for Kenya's proportionally greater need. Kenya's national TB program estimates needs at some $244 million for controlling the disease; its allocation from the Global Fund for the period 2014-217 stands at just $45 million.

As it stands, $1.8 million of the estimated $12.7 million needed to respond to MDR-TB in Kenya was contributed between 2013-2015.

Financial concerns aside, even procuring the right quantity of medicine is a challenge. Even citizens of countries that are not in crisis turn to Kenya for treatment relief for MDR-TB, relying on its experience in treatment of the illness and the comparatively low cost of the eight months of injections: some $2,500 on average.

Western neighbor Uganda only began systematic treatment of MDR-TB in 2012 -- representing 1.4% of new cases reported in 2011. To the south in Tanzania, MDR-TB estimates were 1.1% of cases reported in 2011, and treatment was initiated for 1,000 new cases of MDR-TB the following year. Costs  in both these countries can be as much as 100 times the cost for the same drugs in Kenya.

But it's among the Somali refugee population in Kenya that MDR-TB is flourishing, according to Lucy Chesire, executive director of the local NGO TB-Action. "Thirty percent of MDR-TB [patients] are refugees," she told Aidspan. "We are basically importing MDR-TB. From a human rights perspective, we cannot deny them services. But monitoring, contact investigation and sensitization are the priority."

The response: regional, decentralized and integrated with HIV

Dr Joseph Sitienei, director of the department of prevention of transmissible disease at Kenya's  Health Ministry, considers that surveillance, detection and awareness cannot stop at national borders.

"We need an approach that transcends borders," he told Aidspan. "East Africa should sign a protocol so that all countries follow the same treatment program [for TB]. If someone falls sick in Rwanda or Uganda, and didn't carry with him enough doses, he now runs the risk of not being able to find [the same medicine] and to interrupt his therapy."

Those populations that are highly mobile -- be they bus or truck drivers, economic or political migrants or nomadic pastoralists -- pose a highly complex problem for therapeutic response, said Sitieni, noting that the "resistant TB belt follows the highway from [coastal Kenya's port city of] Mombasa to Uganda".

Kenya will finish revising its new National Strategic Plan for TB by the end of June, paying special attention to improved access to treatment and better identification of vulnerable populations. It is likely that workplans envisioned under the NSP will draw on the planned decentralization of services outlined in the constitution promulgated in 2013.  This  should allow for more targeted placement of health services in communities to be nearer to patients.

"We need to use the county structure put in place by the new devolution in order to identify TB cases at the local level, to improve diagnostics, and to better reach marginalized populations who have limited access to TB services," said Dr Kioko.

Aligning the TB strategy with devolution is smart thinking, agreed Lucy Chesire. However, she cautioned, "TB is always perceived as a vertical program. You will see a district health manager not developing a budget for TB because he knows the government has already taken care of it. It really needs to be embraced by local governments, especially in the hardest-hit regions, so that they can determine their financing priorities."

A meeting held 22-27 April in the western city of Kisumu aimed to carry this message to civil society and local government stakeholders from around the country. The meeting, which brought together the national TB/HIV ICC secretariat, sought to open the Fund's country dialogue process and identify areas requiring joint TB/HIV planning, in line with the Fund requirement that Kenya submit a joint HIV/TB proposal due to high co-morbidity of the two diseases.

How to better incorporate cross-cutting issues of health and community systems strengthening, human rights and gender into the concept note, which should be submitted in the first quarter of 2015, were also discussed.

Although there are concerns among stakeholders in the TB community that integration with HIV could mean subordinating priorities to the better-resourced HIV community, Dr Kioko said that it is only when true integration is achieved that the real work to combat TB and MDR-TB can be done. Citing 2011 figures, Dr Kamene said that co-morbidity of infection is estimated at 39% for TB and HIV in Kenya; among patients with MDR-TB, co-infection incidence is 27%.

"There are many advantages: it is cheaper for the patient, less time is spent, efficiency is increased, but this a question of mindset," said Dr Kioko. "When you want to change a system, there is always resistance, people are afraid to lose their jobs, to lose resources."

[This article was first posted on GFO Live on 28 May 2014.]

To comment on this article, click here.



4. NEWS: Recognition of India’s third gender could boost Global Fund-supported programs for sexual minorities

Karanja Kinyanjui 28 May 2014

The April 2014 ruling will require public facilities to accommodate transgender people, with provisions including separate hospital wards

India's Supreme Court in April ruled that transgender people were a third sex and requiring of basic amenities including separate wards in public facilities such as hospitals. This recognition could help improve effectiveness of Global Fund-supported programming and help reduce the stigma that has prevented transgender Indians from seeking health services.

James Robertson, executive director of India's HIV/AIDS Alliance, told Aidspan that the decision was "certainly a boon for the HIV-related work that needs to be done for transgender communities".

India is home to an estimated 62,000 transgender people, according to a population estimate by the national Department of AIDS Control. Robertson, however, said that figure was "almost certainly a conservative estimate".

Working in 17 of India's 28 states, Pehchan is a project supported by the Global Fund that looks to help improve the lives of men who have sex with men and transgender people. With a five-year budget of some $22.5 million people on a grant running through 2015, Pehchan, which means, identity, holds workshops, trainings and sensitization campaigns with 200 grassroots groups.

Pehchan has also developed a Crisis Response Team curriculum that it has shared with a number of other countries including Uganda, which itself is grappling with draconian laws criminalizing homosexuality.

The CRT model, in addition to holding workshops and sensitizing communities, also teaches grassroots activists how to collect demographic data to develop better profiles and estimates about the size of the MSM and transgender community, as well as how to document and report cases of violence and harassment.

 “Pehchan is an unusual example of the grant working with these groups that has been developed through the national CCM process and in close collaboration with the government of India,” Robertson said.

Stigma and a lack of education are two contributing factors to the rising prevalence of HIV among the transgender population in India. National prevalence based on 2011 statistics collected under an HIV Sentinel Surveilland study was estimated at 0.3%; among the transgender population, prevalence is 8.8%, according to UNAIDS.

While the Supreme Court ruling represents progress for India’s sexual minorities, some of its intended positive action may be hampered by an earlier ruling by the court. In December 2013, the Supreme Court reversed a High Court ruling from 2009 that decriminalized homosexual behavior. This law has had a chilling effect on India's gay community and is wider-reaching than the transgender law, with deeper implications for outreach, awareness and work to reduce stigma against the population.

“From the moment of this ruling last December, we saw an increased level of harassment and violence against members of the LGBT community in India,” Robertson said. “Pehchan outreach workers have been harassed by police, and there are reports of illegal detention of community members and even sexual assault. It has become noticeably more difficult to register MSM in our program as a consequence of the judgment.”

Still, the ruling represents a watershed in the long-running effort to improve the recognition of India's transgender population, which includes the Kothi community in southern Tamil Nadu state. Robertson pointed to a 2009 decision by the Election Commission that allowed transgender people to mark as 'other' their sex on ballot papers, and the national strategic plan (NSP) for HIV 2012-2017 includes an historic targeted intervention for the transgender community.

“Earlier HIV prevention efforts included transgenders as a sub-group of MSM and did not respond adequately to the distinct needs of transgenders and failed to understand the challenges and contexts that contribute to HIV risk for these populations,” Robertson said.

Although HIV prevention for MSM and transgender populations are envisioned under the NSP,  activities like community mobilization and community systems strengthening need to be prioritized by the government. Part of the country dialogue for India as it prepares its concept note under the Fund's new funding model should address these cross-cutting issues, Robertson said.

India has been allocated $562.3 million for HIV for the period 2014-2016, according to an announcement made in March.

Robertson said that India's HIV allocation is likely to be completely devoted to supporting activities under the NSP, although the fate of Pehchan beyond its envisioned end date of September 2015 is uncertain.

 “We have proposed the extension of Pehchan reflecting the priorities of the new national strategic plan, and our proposal is currently being reviewed by various government bodies,” Robertson said.

[This article was first posted on GFO Live on 28 May 2014.]

To comment on this article, click here.



5. NEWS: Djibouti seeking no-cost extension of HIV grant

Agnes Tandler 28 May 2014

Extension should help marshal technical assistance ahead of integrated HIV/TB proposal

Djibouti is negotiating a no-cost extension for its HIV grant with the Global Fund.

Savings of some $1.1 million from grant DJB-613-G05-H will be used to continue the program until November 2014, when funds allocated under the new funding model should be ready for disbursement, according to principal recipient UNDP.

“We want to ensure that there is no interruption from May to December to avoid a gap in financing”, said Nicole F. Kouassi, the former deputy resident representative for UNDP in Djibouti. “The no-cost extension is to assure continuity.”

Djibouti's allocation under the new funding model announced in March is some $20 million. A funding split has yet to be confirmed by the country coordination mechanism, but was allocated by the Grant Management team at the Fund Secretariat as $7 million to HIV, $6 million to TB and $7 million to malaria. As one of 38 Fund-eligible countries with a high co-morbidity of HIV/TB, Djibouti is thus required to submit a joint proposal for the two disease components. That proposal should be ready by October, according to UNDP.

The amount agreed for the current HIV grant, to respond to an estimated 1.4% HIV prevalence rate, under a transitional funding mechanism to ensure no gaps in service provision is $4.5 million.

A small country perched at the tip of the Horn of Africa, Djibouti has struggled to develop the technical capacity needed to forge ahead with the requirements to develop the robust high-impact proposals that the Global Fund is expecting, according to Angela De Tommasi, the project coordinator for Global Fund programming at UNDP.  "Djibouti is a small country, We only have a limited number of experts," she said.

In requiring an inclusive country dialogue drawing stakeholders from all sectors including civil society, as well as robust data upon which to base their proposals for activities supported by the Global Fund, she expressed concerns about tight timelines -- although the timeline for the application will ultimately be determined by the country itself.

UNDP is likely to draw on its own wealth of experience both as PR and as a major technical partner of the Global Fund to help Djibouti develop its concept note. Aidspan understands that the Global Fund will also mobilize technical partners, including France's 5% Initiative, to support Djibouti in its preparation for its NFM application.

UNDP has been PR for HIV and TB in Djibouti since 2013, following an investigation into allegations of fraud by the Office of the Inspector General. Since then Global Fund support has been restricted to essential services, and fiduciary controls have been implemented to mitigate further financial risk.

[This article was first posted on GFO Live on 28 May 2014.]

To comment on this article, click here.



6. NEWS: New funding model in Latin America yields new partnerships -- and new expectations

Pablo Anamaria 23 May 2014

Government decision-makers and civil society stakeholders from across Latin America met in Quito, Ecuador in early April to discuss how to include civil society in decisions about smarter investments in high-impact programs to combat HIV, TB and malaria.

The meeting organized by the Global Fund, in cooperation with the Government of Ecuador and UNAIDS, was developed as a first step towards inclusive and participatory dialogue for countries preparing concept notes under the new funding model (NFM). It was attended by 150 delegates representing 13 implementing countries as well as multilateral and bilateral institutions, and international NGOs.

Silvio Martinelli, manager for the Fund's Latin America and Caribbean (LAC) region, said that while there has been steady economic growth in the region there has not always been a commensurate investment in health.

Global Fund investment in LAC has remained stable in the transition from the rounds-based approach to the NFM for those countries that remain eligible. Among those no longer eligible are Argentina, Brazil, Mexico and Uruguay. Total disbursement stands at some $585 million -- 67% for HIV, 18% for TB and 15% for malaria -- a split that will remain mostly the same under the new allocations announced in March for eligible countries.

That the national delegations included representatives from both Health and Finance ministries indicated a transition in the way health programming has been traditionally handled around the region, according to Anamaria Bejar, the associate director for Latin America of the International HIV/AIDS Alliance.

"It opened the door for a broader dialogue with government partners that have not been traditionally involved in the response to the three diseases," she told Aidspan. "It also provided an excellent opportunity for civil society to be involved in promoting a sustainable way forward for the regional response."

Much of the discussion during the three-day meeting focused on the new requirements for governments to invest more substantially in the response to the three diseases. Under the terms of the 'willingness to pay' provision, 15% of the resources allocated by the Global Fund will be withheld until a country commits to boost its spending by a proportional amount on programs targeting the three diseases. That proportional amount will be determined during the country dialogue process.

"This requirement to increase domestic funding will, within three or four years, be an indicator of the responsibility that governments in the region are taking in terms of long-term response to the diseases,” Bejar noted.

El Salvador was the region's early applicant under the NFM, and delegates were treated to several presentations of lessons learned by the Salvador team.

In particular, noted Javier Hourcade, a regional representative of the International HIV/AIDS Alliance, delegates were exhorted to invest time, money and other resources in ensuring they had quality data at the foundation of all of their discussions and strategies. These data should inform not only the development and implementation of National Strategic Plans, but also the eventual development of concept notes for proposals to the Global Fund.

El Salvador, which has moved relatively smoothly through the NFM process, was successful because the clear objectives of its strategic plan were based on sound data.

Another lesson learned from El Salvador's experience is the importance of assessing the capacity and skillsets of potential sub-recipients prior to signing contracts with them, and providing technical assistance where possible to help improve that capacity. This is particularly critical when it comes to developing plans to help programs reach scale.

All countries that are eligible for Global Fund grants are also eligible to apply for a share of some $44 million in technical assistance approved in March by the Board that is being offered by the Fund itself for concept note development. Other technical partners and donors are also offering technical assistance, which Hourcade said countries in Latin America and the Caribbean should heed as it will be central to the regional goal of refocusing investment in the highest-impact programs.

Participants representing Bolivia, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Nicaragua, Panama, Paraguay and Peru were also reminded of the need to evolve the region's strong social activist movements into engaged actors in health financing. Due to the evolving face of the three diseases, there is a need to evolve civil society's role in fighting them, according to Enrique Chavez, director of advocacy for Observatorio Latino - Aid for AIDS.

Smaller advocacy groups should collaborate in wider networks and be seen as grassroots-level partners for larger, national organizations that at times feel like they have competing agendas, he said.

Equally, within the Global Fund architecture, there is a responsibility of the country coordination mechanism in each country to engage with, and encourage the participation of these smaller groups as they may be best-placed to target specific programs to vulnerable population groups. This includes groups working with indigenous populations, economic and political migrants and women, Chavez said.

"[To ensure the best possible impact of] the NFM, the region needs a more mature and capable civil society, working towards common goals," he told Aidspan.

In the session on Civil Society and Sustainability organised by Hivos and the Ecuadorian NGO Kimirina, Hivos’ HIV/AIDS senior adviser Mirjam Musch stressed that it i’s essential to broaden the concept of sustainability to include both funding and the long-term future of civil society groups, and to incorporate representation of key populations.

Governments, private sector, donors and civil society have to work in partnership, Musch said, in order to include prevention and targeted outreach to key populations in their top priorities. Countries in LAC could look to Argentina for an example of new good practice in this area: the Ministry of Health has set aside specific funds for civil society groups to implement programs at the community level.

[This article was first posted on GFO Live on 23 May 2014.]

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7. REVIEW: Five key recommendations from ICASO for civil society in Global Fund country dialogue

Cleopatra Mugyenyi 28 May 2014

Finding their voice and their place at the table will go a long way towards inclusion in the proposal development process, says ICASO

In a second guidance note as part of its Navigating the New Funding Model[1] series, the International Council of AIDS Service Organizations (ICASO) has developed a series of five key recommendations for better engagement in country dialogue by civil society organizations (CSO) and representatives of key affected populations (KAP).

The Global Fund has mde clear that grants under the new funding model (NFM) will not be approved unless there is documented involvement of those stakeholders or their representatives in the development of the national strategic plan from which the concept note for Global Fund grants must be drawn.

While the Fund has resisted being prescriptive about the extent to which these groups must be involved in the dialogue process that leads to the development of the concept note, there has been an increase in technical assistance available to countries in order to solicit and improve their participation.

The country dialogue process involves a number of stages outlined by the Fund[2], which, as ICASO's note emphasizes, should not be limited to: (i) single meetings of the CCM, (ii) a Global Fund-specific process, and (iii) conclude with the submission of the concept note. 

Country dialogue, according to the note Civil Society and Key Populations and the Country Dialogue,  is described as "an ongoing and dynamic process through which the various partners establish and evolve a shared vision for responding to the diseases in each country",  which ICASO explains will not resolve all issues ahead of concept note submission. 

It suggests three areas of opportunity for CSO engagement: (i) in documentation of impact through evaluation of programs, (ii) in the establishment of the health sector and disease specific landscape in country, and (iii) in expanding the space for the inclusion of human rights and the input of KAPs in program development and implementation.

As of April 2014, when the note was published, the number of countries that have initiated their country dialogue process constitutes only a handful of the 123 countries eligible for Global Fund support from 2014-2016, among them three early applicants: Democratic Republic of Congo,  Myanmar and Zimbabwe.

Zimbabwe's experience is described in the guidance note as an example of an expedited country dialogue process.  Led and coordinated by the CCM, with the inclusion of CSOs and KAP representatives, the process took one month from consultation to concept note development.  This expedited process was possible as the NSP was already in place[3]

Myanmar developed its concept note before the transition to the NFM.  The pre-existing concept note drafts were used during the country dialogue processes and it was noted that this limited the influence that the process had on the final concept notes.

 The DRC country dialogue process began eight months before concept note submission.  This process was led by the CCM and involved a wide variety of stakeholders from across the country.  This longer period of country dialogue enabled CSOs and KAP representatives to ensure that the needs of KAPs were comprehensively covered in the concept note. 

Finally, the guidance note addresses Moldova's work to bring CSOs and KAP representatives into caucus to develop a comprehensive strategy that will be used to advance their priorities during the country dialogue process.

The guidance note provides 5 key recommendations for effective country dialogue and 3 points for managing the process: 

  1. Develop a cohesive strategy by CSOs and KAP representatives before the country dialogue will provide better outcomes during concept note development. 
  2. Give information on the NFM to CSOs and other stakeholders through workshops will allow for higher quality participation during country dialogue. 
  3. Engage with the development and review of the national strategy is extremely important in order to assess the quality of KAP data. 
  4. Allow for mechanisms to enable KAPs to contribute will improve communication with constituents and improve transparency of the country dialogue process. 
  5. Document comprehensively all meetings and resolutions along with invitations to non-civil society CCM members will strengthen the civil society position within CCMs and during concept note development. 

Management of the country dialogue process may be improved by ensuring all documents and meetings are in the appropriate language, that there is inclusion of remote and rural communities, and that country dialogue is approached as more than just a series of meetings leading up to concept note submission. 

Country dialogue should be positioned as an inclusive process of review, development, and adaption of budgeted disease-specific NSPs along with the process of raising funds to implement parts of the NSPs through development of a concept note.        



[This article was first posted on GFO Live on 28 May 2014.]

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