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The Technical Review Panel has highlighted gaps and shortcomings in the concept notes that continue to roll in on schedule, as countries seek to master the complexities and requirements of proposal development under the new funding model (NFM).

Confusion over what it means for a component to be designated “over-allocated” or “significantly over-allocated” may make it harder to persuade some governments to increase domestic resources for programmes supported by the Global Fund. 

Representatives of Kenyan civil society concluded a three-day workshop on 22 August with the endorsement of a draft 16-point charter to guide future participation by community-based organizations in Global Fund processes, beginning with country dialogue and concept note development under the new funding model (NFM).

A new Global Fund publication to provide investment guidance to the Eastern European/Central Asian region emphasizes the need for domestic financing to complement declining international aid as one of the strategic priorities to help reverse the spread of HIV and TB across the region.

The Eastern European/Central Asian Union of People Living with HIV (ECUO) has been invited to submit a concept note under the new funding model following the approval of their expression of interest.

The Technical Review Panel (TRP) has highlighted some of the most common gaps and shortcomings of the concept notes submitted since the full adoption of the new funding model (NFM), even as modifications to expedite the review process for straightforward proposals are instituted.

In the monthly progress update about the NFM to the Board, the Secretariat emphasized that concept notes were being submitted roughly in line with a schedule developed prior to the roll-out of the NFM. Twenty-three concept notes were submitted to the TRP for review in July. By mid-September it is anticipated that another 33 concept notes will begin the screening process, bringing the total of NFM applications to 66 thus far, excluding early applicants, for a grant portfolio worth as much as $6.02 billion.

These figures are slightly behind predictions made prior to the NFM roll-out that 72 concept notes would be in-hand by 15 August, but it is expected that the cumulative number of concept notes to be submitted during the allocation period 2014-2017 will reach 280 -- slightly more than half of which (146) should be with the TRP before the end of 2014.

Thus far, the majority of the concept notes submitted have been to secure resources for malaria programming. It is anticipated that the number of concept notes for TB and HIV -- as well as joint TB/HIV proposals -- will increase in the next submission windows.

An expedited review by the Grant Approvals Committee of concept notes that are not eligible for incentive funding has been instituted by the Secretariat, in what appears to be an effort to bring as many technical resources as possible to those concept notes requiring more attention.

The 41 countries in Band 4 -- a portfolio worth a total of $1.1 billion -- are not eligible for incentive funding.

Although a disease split was included in the allocation amount that was communicated in March to each eligible country, countries were allowed, subject to approval, to modify that split. To date, the Secretariat has agreed the split for 40 countries, excluding those eligible for funding for only one disease component.

In a bulletin of lessons learned that was also shared with the Board, the TRP noted a number of gaps and shortcomings in the concept notes received, some of which have required a refocusing of attention by country coordinating mechanisms (CCMs) and a resubmission.

The TRP reminded CCMs of the technical assistance available from both the Fund itself as well as technical partners in order to address these shortcomings and emphasized the need for all concept notes to be based on sound, data-driven evidence collected at national and sub-national levels.

Among the thematic areas of concern flagged by the TRP were:

Key Populations

A thorough analysis of epidemiological data, backed by clear explanations of how proposed interventions will target and reach key populations, has been lacking in some proposals. More care must be taken to ensure that rights and gender issues are not only identified, but that programming to address them is strong.

A number of concept notes reviewed thus far failed to include a broad range of interventions to address gender, gender-based violence and the rights of women and girls. Nor was there enough demonstrated support for the needs of young people (especially adolescent girls), who are at extremely high risk in generalized HIV epidemic settings. Budget considerations must also be made for human rights and key population activities.

Sustainability

The TRP recognized that some countries lack the resources and capacity to ensure program sustainability beyond the life of Global Fund grants. However, this lack of resources should not prevent countries from showing how they intend to ensure that these programs continue, particularly with respect to the need to integrate disease programs and health system strengthening into delivery of primary health services through the national health system. This lesson emphasizes the move away from vertical programming towards more cost-effective integrated programming that is central to the NFM's health policy objectives.

Disease/Program split

Although 40 countries have had their program split approved, the TRP noted "a general lack of engagement of experts on health systems strengthening" and the apparent exclusion of some stakeholder groups from "thoughtful and robust country dialogue around program split and prioritization of interventions".

Prioritization

Applicants thus far have struggled to present a clear and prioritized concept note that explicitly explains strategic choices made in the allocation of limited resources to high-impact, cost-effective activities. The TRP noted: "Concept notes that fail to reflect evidence-based prioritization based on geographic and population data and lessons learned from past implementations will be asked by the TRP to undergo iteration before moving to grant-making".

Implementation of new WHO guidelines on ART

The TRP expressed concerns that some HIV concept notes have failed to "holistically consider (sic) the country’s readiness to move to a CD4 threshold of 500, nor did they appear to acknowledge the aspects of the [WHO guidelines] that allow for prioritization of people with CD4 less than 350 and for discordant couples and key populations".

Also of concern is countries' ability to find the appropriate balance between prevention and treatment, with many countries seemingly targeting the lion's share of their funding allocation to treatment, specifically the purchase of anti-retroviral therapies.

"Without appropriate prevention efforts, ART will ultimately prove unaffordable and, therefore, unsustainable," the TRP brief said. "If a major portion of the resources requested is going to ART scale-up, the concept note should make clear how essential prevention services are to be sustained through other national or donor resources as ART is scaled up."

In the letters that the Global Fund sent to countries informing them of their allocations for 2014–2017 under the new funding model (NFM), some components were identified as “over-allocated” or “significantly over-allocated.”

The “over-allocated” label did not mean that the component was receiving more money than was needed to fight the disease. It was simply a term used by the Global Fund to describe a component whose final allocation exceeded the amount than the NFM formula initially said it should receive.

But the “over-allocated” label is being misunderstood in ways that could be harmful to the Global Fund and to people affected by HIV, TB and malaria. Some government officials have said that if a component is considered “over-allocated,” it must be getting more than enough money and so there is no need to look for more domestic resources.

It would be wrong to conclude that “over-allocated” components received all the money they required to fight the diseases; the reality is that most of these components had their allocations reduced by 25% from their disbursements in 2010-2013.

In its July progress report on the NFM, the Secretariat acknowledged that the allocation letters “have had unintended consequences on domestic resource mobilization efforts.” The progress report emphasized that no country is receiving enough money to fight the three diseases, including countries with components designated as over-allocated in the context of the Global Fund’s allocation methodology.

But that message is not getting through. It isn’t getting through because the Global Fund is not doing a good enough job of explaining the terminology it uses and because it has failed to make public many details on how the allocation methodology is being applied. In the absence of information, people tend to jump to erroneous conclusions.

Some Aidspan staff recently participated in a meeting involving local and national stakeholders knowledgeable about the Global Fund. Very few of them knew what “over-allocated” and “significantly over-allocated” meant. One of the participants said that such language was a “gift to politicians who want to cut domestic financing for the diseases.”

What exactly does “over-allocated” mean, then? In order to determine what the base allocation should be for each component, the Secretariat used a formula based on ability to pay (income level) and burden of disease. The formula produced an initial allocation that was then adjusted for certain qualitative factors, such as the amount of funding the component was receiving from other donors.

The next step was to compare the formula-driven allocation to the funding that the component received recently (i.e. for 2010-2013). If that amount exceeded the formula-driven allocation by more than 25%, the final allocation for that component was based on the amount of recent funding, not the formula, minus (in most cases) 25%. The component was then designated “over-allocated.”

If a component was labeled “significantly over-allocated,” this meant that the amount of recent funding exceeded the formula-driven allocation by at least 50%. The allocations for these components were also based on recent funding, again minus around 25%.

The terms “over-allocated” and “significantly over-allocated” are constructs of a very complicated allocations methodology and they should be understood in that context. Over-allocated or significantly over-allocated components are not getting all the funding they need. On the contrary, they need as much new funding as they can find, including from domestic sources, just to maintain the level of service that was being provided in 2010-2013.

The confusion over terminology may prevent countries from finding other ways to fight the three diseases – including most critically from national budgets. To help allay the confusion, the Global Fund should be more forthcoming about how its allocation methodology was applied to determine the allocations for 2014-2017.

The allocation methodology is described in a Global Fund publication, “Overview of the Allocation Methodology,” and in an Aidspan guide, “Understanding the New Funding Model.”

Representatives of Kenyan civil society concluded a three-day workshop on 22 August with the endorsement of a draft 16-point charter to guide future participation by community-based organizations in Global Fund processes, beginning with country dialogue and concept note development under the new funding model (NFM).

More than 40 participants from 30 different grassroots organizations attended the training facilitated by Aidspan and collaborating partners including the International HIV/AIDS Alliance and AIDS Accountability International.

The training was based on seven case studies that explored the Global Fund's relationship with Kenya, and required participants to evaluate national data on health indicators, impact and other statistics related to: domestic health financing, procurement, national response to the three diseases, community systems strengthening, harm reduction, and programs targeting key populations.

In identifying their priorities to be included in the draft charter, the civil society representatives emphasized expanded access and use of health and health financing data related to Global Fund program implementation as the best way to hold government accountable to its commitments to the fight against HIV, TB and malaria.

Kenya is one of several countries to develop a Civil Society Charter to strengthen the ability of civil society to engage at the highest levels of decision-making related to the allocation of resources and implementation of Global Fund-supported programming.

The charter development process, first launched in southern African countries including Malawi, Swaziland, Tanzania, Zambia and Zimbabwe, provides tools and a framework for action and improved participation based on a consensus of priorities across the civil society sector.

In drafting their charter, Kenyan participants identified and ranked the following priorities:

Once the draft charter has been reviewed and critiqued by all stakeholders, it will be validated and disseminated widely, hopefully timed to coincide with the finalization of Kenya's draft concept notes.

Kenya is set to submit two concept notes by early 2015: a joint proposal for TB and HIV and a separate proposal for malaria. Both will contain some resources for health system strengthening. Kenya's total allocation under the NFM, announced in March 2014, was $495.4 million for the period 2014-2017.

Recognizing that the Eastern European/Central Asian region is alone globally with a steady increase in HIV prevalence and growth of MDR-TB, the Global Fund has, in consultation with an array of local, regional and international partners, developed new guidance to promote domestic financing and strategic priority setting.

The impetus for the guidance, beyond the expanding burden of disease, is the practical reality that EECA countries are among the most likely to 'graduate' into income classes that would make them ineligible for Global Fund support, particularly as the new funding model (NFM) reorients resources towards those countries with the lowest incomes and the highest burdens of disease.

Two principles define the investment guidance: alignment with other partners' policies, plans and strategies to achieve disease-specific targets set at the country level; and differentiation and ownership to reflect the need to tailor priorities to specific national contexts.

What this means, essentially, according to Dr Steve Fabricant, an independent consultant in health economics and policy, is that the Global Fund is trying to define, for its own work, how to support different countries at different stages of economic development -- with a finite amount of resources.

Equally, however, Fabricant told Aidspan in an e-mail while providing latitude for countries to set their own priorities, the guidance also reinforces the Fund's emphasis on harm reduction and ARV treatment programs for key populations, as well as prioritizing adequate support for TB. Future guidance would do well to include what Fabricant called "a clearer indication of the relative priority given to future requests for support for health system strengthening”.

For representatives of the region's civil society groups, the guidance comes at a critical time, as it will help to help leverage the new requirements for transparency and inclusion in country dialogue to help develop concept notes.

Andrey Klepikov, the executive director of the International HIV/AIDS Alliance in Ukraine said the investment guidance sets ambitious regional targets based on the funding available in each country. But he notes that for countries like Ukraine, which was classified as significantly over-allocated under the initial rounds-based approach, the size of the envelope announced in March for HIV funding represented a significant decline from previous levels.

The risk is that projections of future funding contained in the investment guidance could create the wrong impression that there will not be further cuts in assistance to countries in the region; for example, he notes that the HIV envelope for Ukraine under the NFM will mean 50% less Global Fund support for the country from 2015.

"The investment guidance should be a tool that, when applied correctly, may avoid further cuts in funds available to respond to the particular needs of key population groups: men who have sex with men and people who inject drugs," he said.

Klepikov also expressed disappointment that the guidance seemed to deprioritize the needs specific to reaching men who have sex with men. "I’m actually surprised to see so little attention to MSM in the strategy. Clearly, from the Ukrainian perspective I have to state that similarly to other countries of the region, the HIV epidemic situation with MSM is worrisome," he said. "It is projected that, should there be no increase in the level of response, MSM will begin to drive the HIV epidemic in Ukraine by 2020. So without prioritizing prevention and treatment services, we risk a crisis scenario."

Nor did the guidance address the silent challenge of Hepatitis C that is confronting the region, primarily due to how rife it is within a major target group for Global Fund-supported programming for HIV and TB: people who inject drugs.

"The investment strategy should not only mention the issue, but actually propose a way to directly and indirectly address this issue, and be among the key stakeholders prioritizing cost-effective funding solutions in addressing Hepatitis C issues," Klepikov said.

For Ivan Varentsov, a Moscow-based independent HIV expert,  it is not only the priorities that give pause.

"My concern is about the targets determined in this guidance with respect to domestic co-financing and especially about the timeframe given to achieve these targets," he said.

The document projects that by the end of the current allocation period -- 2017 -- the region's lower/lower-middle income countries are expected to start covering at minimum 60% of funding for ARV treatment, diagnostic services and adherence support; the same holds true for TB. For middle income countries, that number rises to 75% and for upper middle income countries, 100% -- targets that, for all intents and purposes, mean that by 2017, no upper middle-income country will be eligible for Global Fund support for HIV or TB treatment.

When ten of the 18 countries in EECA that are receiving Global Fund grants are fully or partially dependent on those resources to purchase ARV drugs, the implications for the future prompt concern.

"Taking all this into account I strongly doubt that given targets are realistic and achievable within the prescribed timeframe," Varentsov said. “It is also not clear how the Fund expects certain EECA countries to find this money within their national budgets in three years; the investment guidance doesn’t cover this issue".

According to Varentsov, the investment guidance should be updated with evaluations by the Global Fund of countries' ability and willingness of countries to pay, in order to harmonize the targets with the practical realities on the ground, and "extend the targets for at least one more allocation period".

The Eastern European and Central Asian Union of People Living with HIV (ECUO) has passed the first hurdle in its effort to be a driver of Global Fund-supported programming, becoming one of 16 entities invited to submit a proposal for a regional initiative under the new funding model (NFM).

Of 43 regional proposals received, for a total of some $600 million, 16 were invited to submit concept notes. These submissions are expected in early 2015, to access $200 million approved by the Global Fund Board for regional initiatives to be implemented from 2014-2017.

ECUO, together with the Eurasian Harm Reduction Network, has asked for $7 million to promote domestic financing for HIV treatment arouind the region. The funds would also be used to encourage a more holistic approach to harm reduction in a region where the primary method of transmission of HIV is among injected drug users sharing dirty needles. World Health Organization estimates conclude that 80% of new infections recorded in EECA are related to injected drug use.

The program will emphasize advocacy work at the regional level to help encourage individual countries to shoulder a larger percentage of the costs of prevention, diagnosis, treatment and care in the national HIV response. As donor support dwindles, there is immense concern around the region that the gap being left will not be filled in a timely fashion by national governments, said Aleksandra Volgina, the senior advocacy officer for ECUO.

Another program objective is to raise awareness of the real nature of HIV treatment; Volgina noted that current conventional wisdom suggests that all that is needed to manage HIV is to "take the pills" when the reality of anti-retroviral therapy is more complicated. Testing and counselling remain crucial components of any treatment regimen and more work needs to be done to emphasize this.

The number of countries included in the regional initiative has yet to be determined; regional dialogue coordinated by the two partners is ongoing, drawing representatives from 16 partners in the ECUO network.

Technical support has been solicited from the UN and WHO to develop the regional proposal, which is likely to include some elements of the Global Fund-supported 'Harm reduction works: fund it' initiative led by EHRN in six countries.

The Global Fund's Strategy Investment and Impact Committee (SIIC) is beginning to collate the results of a new, 11-question survey of implementing country stakeholders so as to contribute to the emerging narrative about the high points and challenges in moving through the new funding model (NFM) process.

This is issue 250 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

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