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Global Fund Observer
NEWSLETTER
Issue 277: 17 December 2015
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CONTENTS OF THIS ISSUE:
1. NEWS AND ANALYSIS: Fund sets $13 billion replenishment goal
The Global Fund’s $13 billion replenishment target is $2 billion less than the target set
for the last replenishment. The total funding need for 2017-2019 in countries where the
Global Fund invests is estimated at $97.5 billion. Questions will likely be raised about
both the target and the funding needs estimate.
2. NEWS: Despite serious concerns about risk, Global Fund approves $316 million in new
funding for TB/HIV grants to Nigeria
The Board has approved $316 million in new funding for Nigeria’s HIV and TB
programs to implemented by four PRs. Nigeria’s size and disease burden, and the need to
maintain and scale up essential services, outweighed serious concerns about operational
and systems weaknesses and risks. However, the funding comes with a number of
conditions attached. Further, the Secretariat is adopting a differentiated approach to grant
management in Nigeria, one that involves (among other things) recruiting state-level
fund portfolio managers.
3. NEWS: Prevention materials are still getting through to the “uncontrolled areas” of Eastern
Ukraine
The Alliance for Public Health (formerly the International HIV/AIDS Alliance Ukraine),
working with partner organizations, has managed to deliver HIV, STI, and hepatitis C
prevention materials to the areas of Eastern Ukraine not controlled by the government.
Delivering TB medicines has proved to more difficult.
4. NEWS: Among second batch of regional concept notes, a community approach to
treatment access in West Africa
Treatment access for HIV is lower in West Africa compared to other regions. A regional
proposal plans to address this problem using a community approach.
5. NEWS: Aidspan finds gaps in the Global Fund’s response to HIV/AIDS epidemic in
children
An analysis of 22 concept notes and 16 grant agreements undertaken by Aidspan reveals
that children may still not be prioritized under the new funding model.
6. ANALYSIS: Global Fund promises a major effort to expand investment in human rights
programming
Since the advent of the new funding model, the Global Fund has improved its guidance
on including human rights initiatives in concept notes. But the Fund plans to step up
efforts to expand investment in human rights.
7. NEWS: Database of civil society organizations in Burkina Faso boosts the community
response
A database of community organizations in Burkina Faso was instrumental in developing
that country’s concept note on health system strengthening. Using the database,
organizational weaknesses were identified, particularly concerning the coordination of
activities, But the process of creating the database was long and complex.
8. NEWS: Funding in the amount of $224 million approved in November
In the latest wave of funding, 22 grants from 14 countries and one regional organization
were approved. This marked the first time that external funding has been used to fund an
initiative on the UQD register.
9. NEWS: Special arrangements established for funding applications from four Middle East
countries and territories
The Board has waived certain requirements for funding applications from Iraq, Palestine,
Syria, and Yemen because of the current political context and challenging operating
environments in these countries and territories.
10. NEWS: Major focus on sustainability in November funding approvals
That the Global Fund is strongly promoting sustainability measures – and not just in
middle-income countries – was evident in the grants approved by the Board in
November.
11. NEWS: In brief
This article reports on the establishment of a new global fund to fight malaria and other
tropical diseases; and on a campaign by civil society organizations in Malawi to organize
for greater impact.
12. ANNOUNCEMENT: GIZ extends deadline for applications for technical assistance
in its main program areas
GIZ has extended to 31 December 2015 the deadline for applications for technical
assistance in its three main program areas: country coordinating mechanisms, health
systems strengthening, and grant management.
ARTICLES:
1. NEWS: Fund sets $13 billion replenishment goal
Funding needs from all sources are estimated at $97.5 billion
Funding gap of $19.5 billion projected
David Garmaise
17 December 2015
The Global Fund has a set a fundraising target of $13 billion for its Fifth Replenishment for
2017-2019. This is $2 billion less than the target it set for the Fourth Replenishment for 20142016, but almost exactly $1 billion more than actual pledges received by the time of the
Fourth Replenishment conference in 2013.
This information is contained in a report describing the Fund’s investment case for the Fifth
Replenishment, which was released publicly on 17 December, the day of the replenishment
preparatory meeting in Tokyo, Japan.
If the $13 billion goal is reached, the Global Fund said that this would result in savings of up
to eight million lives through programs supported by the Fund, and avert up to 300 million
new infections across the three diseases.
The Fund said that an investment of $13 billion would also lead to economic gains of up to
$290 billion over the coming years and decades. This figure is based on broad estimates by
partners on the return on investment for implementing each of their respective global plans.
These estimates assess the economic value of better health and a more productive society
through productivity and consumption gains, including through household savings, and
calculate that each person who goes on lifesaving treatment is a potential contributor to the
economic health of a community.
The Fund said that because of the significant progress made in recent years, the world is on
the “right side of the tipping point,” to control the three diseases provided increased
investments are forthcoming and provided they are used more effectively. Without strong
investment, the Fund said, progress could be reversed and there could be an alarming
resurgence of the diseases.
According to the investment case, total funding for 2017-2019 to fight the three diseases in
countries where the Global Fund invests is $97.5 billion. The estimated funding needs are
based on global plans produced by the Fund’s partner organizations. These plans include:
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Fast Track – Ending the AIDS Epidemic by 2030, published by UNAIDS prior to
World AIDS Day 2014;
UNAIDS Strategy 2016-2021, published in 2015;
The End TB Strategy, published by the World Health Organization in 2014;
The Global Plan to End TB, published by the Stop TB Partnership in 2015;
The Global Technical Strategy for Malaria 2016-2030, endorsed by the World Health
Assembly in May 2015; and
Action and Investment to Defeat Malaria, published by the Roll Back Malaria
Partnership in 2015.
The Global Fund said that all three global plans have included elements of health systems in
their costs, to varying degrees.
Table 1 provides a breakout of the funding needs for 2017-2019 by disease.
Table 1: Breakout by disease of estimated funding needs for 2017-2019
Disease
Estimated needs ($)
HIV
66.1 billion
TB
17.7 billion
Malaria
13.7 billion
Total
97.5 billion
The Global Fund’s $13 billion target represents 13% of the estimated funding needs. The
Global Fund projects that domestic financing will continue to grow significantly and that
funding from external donors other than the Global Fund will remain steady. Projections for
the Global Fund, other donors and domestic investments combined represent only 80% of the
total estimated funding need for 2017-2019, leaving a funding gap of $19.5 billion. Table 2
provides a breakout by source of funding.
Table 2: Breakout by source of funding for estimated funding needs for 2017-2019
Source
Estimated needs
$
%
Domestic investments
41.0 billion
42%
Global Fund
13.0 billion
13%
Other Donors
24.0 billion *
25%
Funding gap
19.5 billion
20%
Total
97.5 billion
100%
* The investment case actually estimates the Other Donors share at $23.4 billion. However, if we use that figure
in Table 2, we would need to alter either the total ($97.5 billion) or the funding gap ($19.5 billion) which would
conflict with information found elsewhere in the investment case. The investment case does not mention a figure
for the funding gap, but says that investments from domestic sources, other donors and the Global Fund
combined would reach 80% of the estimated funding need.
The Global Fund said that total funding needs are expected to peak in 2020 and then decline.
It also said that the Fund’s share of the total resources allocated to the three diseases will
decline beginning with the Fifth Replenishment. (See the figure below).
Source: Global Fund Investment Case Summary – Fifth Replenishment 2017-2019
According to the Global Fund, domestic financing is significantly increasing and already
accounts for more than half of funding for HIV, more than three-quarters for TB and around a
quarter for malaria. Nevertheless, the Fund said, external financing remains essential.
Comparisons to the funding need estimate for 2014-2016
The funding needs estimate of $97.5 billion is 12% higher than the $87 billion funding needs
estimate produced for the Fourth Replenishment. Tables 3 and 4 provide a breakout of the
two sets of estimates by, respectively, disease and source of funding.
Table 3: Comparison of the funding needs estimate,
2017-2019 vs. 2014-2016: by disease ($)
Disease
Fifth replenishment
2017-2019
Fourth replenishment
2014-2016 *
HIV
66.1 billion
58.0 billion
TB
17.7 billion
15.0 billion
Malaria
13.7 billion
14.0 billion
Total
97.5 billion
87.0 billion
* The estimate for 2014-2016 was prepared in 2013.
Table 4: Comparison of the funding needs estimate,
2017-2019 vs. 2014-2016: by source of funding ($)
Source
Fifth replenishment
2017-2019 *
Fourth replenishment
2014-2016 *
$
%
$
%
Domestic investments
41.0 billion
42%
37.0 billion
43%
Global Fund
13.0 billion
13%
15.0 billion
17%
Other Donors
24.0 billion
25%
24.0 billion
28%
Funding gap
19.5 billion
20%
11.0 billion
13%
Total
97.5 billion
100%
87.0 billion
100%
* The estimate for 2014-2016 was prepared in 2013. See explanation of the Other Donors share for 2017-2019
in the note attached to Table 2.
The funding gap increased from $11 billion in the 2014-2016 funding needs estimate to $19.5
billion in the estimate for 2017-2019.
However, Global Fund officials caution against reading too much into the comparison
between the two sets of numbers because, they say, a much more rigorous methodology was
employed for the 2017-2019 estimates.
Analysis
Some questions are bound to be raised about the decision to go with a goal that is $2 billion
lower than the $15 billion goal of the Fourth Replenishment. Why would the Fund be
lowering its sights at a time when the needs are growing? The $13 billion goal for 2017-2019,
should it be reached, will still leave an unfunded gap of $19.5 billion.
On the other hand, given the current economic and political context, and the competing
demands for development and other aid, perhaps the $13 billion goal is more realistic. And
perhaps it is a goal that is reachable. Falling $3 billion short of its $15 billion goal for 20142016 did not exactly enhance the Fund’s image.
And the Global Fund can argue that with domestic investments in the three diseases and in
health systems continuing to increase at a rapid pace, there is less need now for external
financing, including from the Fund.
Finally, $13 billion is still $1 billion (or 8%) higher than what was raised in the last
replenishment. For countries with currencies that have depreciated significantly against the
US dollar, the increase is more like 20%.
Some questions may also be asked about whether the $97.5 billion funding needs estimate
fully reflects what the actual needs are.
The estimated needs for HIV is $66.1 billion. There have been several developments in the
last three years, including UNAIDS’ new 90-90-90 strategy – by 2020, 90% of people living
with HIV know their status; 90% of these people tested will be on treatment; and 90% of
those on treatment will be virally suppressed – and new treatment guidelines which call for
people who are diagnosed with HIV to be put on treatment immediately, which are expected
to add significant costs of fighting HIV. Have these additional costs been fully factored into
the needs estimate? Global Fund officials say they have.
For TB, it is worth noting the funding needs estimate is based on the standard investment
scenario outlined in the Global Plan to End TB, where its 90-(90)-90 treatment targets are
reached in 2025, as opposed to a more accelerated strategy, also described in the Global Plan,
whereby these targets are reached in 2020. (In the TB world, 90-(90)-90 means 90% of all
people with TB diagnosed and put on treatment; 90% of key populations reached as part of
this approach; and 90% of all people diagnosed with TB treated successfully.)
And for malaria, the investment case noted that the costs of implementing the Global
Technical Strategy for Malaria may be underestimated because they do not include new tools
that are expected to be costlier yet will be essential to fight the emergence and spread of drug
and insecticide resistance.
In addition, the investment case said that the Global Plans for the three diseases have
included elements of health systems in their costs “to varying degrees,” which may raise
questions about whether the costs of health systems strengthening have been adequately
covered in the funding needs estimates.
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2. NEWS: Despite serious concerns about risk, Global Fund approves
$316 million in new funding for TB/HIV grants to Nigeria
Grants are considered critical to maintaining and scaling up existing services
Fund says the standard approach to risk mitigation in Nigeria is not sufficient
The Secretariat is recruiting state-level fund portfolio managers for Nigeria
Tunde Akpeji
16 December 2015
Despite serious concerns about operational and systems weaknesses and risks, the Board has
approved five TB/HIV grants to Nigeria totaling $510 million, of which $316 million is new
funding. The announcement was made on 14 December. In approving the grants, the Board
was acting on the recommendations of its Grant Approval Committee (GAC). Included in the
$510 million award is $26 million in incentive funding. Additional initiatives valued at $127
million were placed on the register of unfunded quality demand. See the table for details.
Longstanding weaknesses in the areas of financial, supply-chain, non-health product
procurement and grant management have led to fraud and misappropriation of grant funds in
the past. Nevertheless, the Fund decided that because of the size of the country, its high
disease burden, and the importance of the Nigeria grants in the overall portfolio – Nigeria
received the largest allocation of any country ($1.1 billion) – not to approve the grants, in the
words of the GAC, is “not a preferred option at this stage if the Global Fund is to fulfill its
mission.”
Table: Funding for Nigeria TB/HIV grants approved by the Board, December 2015 ($ million)
Grant name
Principal
recipient
Approved Funding
Existing
New
20.3 m
18.3 m
128.0 m
162.8 m
NGA-HSFHNG
Society for Family Health
Nigeria
NGA-H-NACA
National Agency for Control
of AIDS
NGA-H-ARFH
Association of Reproductive
and Family Health
8.0 m
NIL
NGA-T-ARFH
Association of Reproductive
and Family Health
18.6 m
81.8 m
NGA-T-IHVN
Institute of Human Virology
Nigeria
18.9 m
53.1 m
193.8 m
316.0 m
Totals
Of which,
incentive
funding
Added to
UQD
register
509.7 m
26.3 m
127.3 m
509.7 m
26.3 m
127.3 m
Total
Discrepancies in totals due to rounding.
The board’s decision came with conditions. The Secretariat must recover all outstanding
amounts related to a 2011 audit conducted by the Office of the Inspector General. It must also
continue to enforce risk-mitigation measures currently in force and enhanced measures
planned for the new grants. The last part was a reference to the fact that interim findings from
another audit currently being conducted on Nigeria’s grants by the OIG have identified
additional weaknesses and concerns. The OIG is also investigating allegations of fraud and
misappropriation of grant funds by a government sub-recipient.
The Board held back part of Nigeria’s TB/HIV allocation so as to preserve flexibility “to
address uncertainties and potential needs associated with a differentiated approach” (see
below) and additional OIG findings. The Nigeria country coordinating mechanism had
applied for the full TB/HIV allocation of $321 million in new funding. The Board signaled
that it may in future recommend further funding from the allocation.
As well, the Board decided that the Secretariat can redistribute among the four principal
recipients some of the funding that was awarded. The Technical Review Panel, however,
would have to approve redistributions that involve “material change” from the program.
The incentive funding award of $26 million was conditional on Nigeria matching this amount
through domestic contributions at federal or state level. The release of the incentive funds is
being held up because no government ministers were in place for the Secretariat to engage
with until almost mid-November.
Risks and challenges in Nigeria
Historically, grants to Nigeria have faced substantial systematic and operational risks and
challenges. Key risks identified by the Secretariat include the following:
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grants not achieving targets, including for key indicators such as antiretroviral therapy
and TB diagnosis;
fiduciary risks, including government PRs struggling to oversee countrywide disease
responses;
insufficient capacity to ensure that basic health services are in line with guidance and
national standards;
inadequate monitoring and evaluation, poor data quality, and poor quality of
electronic health information systems; and
systematic weaknesses and risks in procurement and supply chain management
systems.
The OIG’s current audit and investigation
It appears that the Secretariat was briefed on the preliminary findings of the current OIG
audit and investigation while Nigeria’s concept note was in the grant-making stage. The
concept note remained in grant-making for a full year, well above the norm.
The Secretariat has frozen all disbursements to the SR under investigation. According to the
GAC, the Global Fund will provide no further funding to the affected SR “unless and until
actions to establish controls and assure no recurrences are confirmed, including structural
changes and robust risk mitigation measures to address the underlying root causes are in
place.”
Measures already taken in 2015 to respond to the OIG’s initial findings include the
installation of a fiscal agent to ensure that program funds are spent in strict compliance with
Global Fund policies and in line with work plans and budgets; and initiatives to build the
financial capacity of the PRs. Additional measures to be implemented in the near future
include adjusting the implementation arrangements of supply chain management for the
government PRs; and increasing the role of the local fund agent. The Secretariat is also
considering fully outsourcing of non-health procurement management.
In its report, the GAC said that “the preliminary OIG findings will have profound
ramifications for how the Global Fund works in Nigeria.” While the financial management
risk is being substantially mitigated by the appointment of a fiscal agent, the GAC said,
“more work will be required in understanding the root causes of the identified systemic risks
and their resulting effects on the programs and achieving the mission of the Global Fund in
Nigeria.”
The GAC said that the federal government will need to be persuaded to take action to ensure
that its grants are more effectively managed. Recognizing that a standard approach to risk
mitigation will not be adequate for Nigeria, the Secretariat and OIG will work with the
government and development partners to develop a strategic risk management framework
tailored to Nigeria’s particular needs. The framework will include laying out a roadmap and
milestones for the medium and long term.
Other measures to be implemented in the short term involve adjustments to the
implementation arrangements for the grants, including the approach to supply chain
management; and the inclusion of strong conditions in the grant agreements (usually referred
to as “grant confirmation forms” under the NFM).
The GAC also stressed the need for strengthened safeguards with early warning mechanisms
so that the OIG audit is not the only time that the full scale of major risk issues are discussed.
The epidemiology
The grants will be implemented in Africa’s largest country whose 170 million culturally
diverse people, half of who live in urban areas, are disproportionately made up of young
persons. Nigeria has high burdens of HIV and TB, including multi-drug-resistant TB.
Inadequate coverage of both diseases remain a challenge, as do high levels of stigma.
Figures from 2013 cited in the report, show a generalized epidemic that remains high despite
a decline in HIV prevalence. ART and prevention of mother-to-child transmission coverage
remain low. The country’s TB rates remain of concern. The GAC report explained that
“given the high prevalence rates of HIV and TB, as well as a growing population, the success
of the Nigeria TB/HIV program is essential for global efforts to fight these diseases.”
The new grants
Given the challenges in implementing grants in Nigeria, and the fact that Nigeria is a large
federal state, the Global Fund is planning to implement a differentiated approach to grant
management processes, one that would see more direct engagement between Fund officers
and state level officials. The Secretariat said that the recruitment of state-level fund portfolio
managers within the Secretariat was being finalized and Secretariat resources have been
strengthened.
The objectives of the program are to reduce new cases of HIV; to improve the quality of life
of people infected with and affected by HIV; to improve access to prevention, diagnosis and
treatment services for HIV and TB, including drug-resistant TB; and to help restore public
confidence in primary health care services.
Among other things, the program will provide HIV prevention services to key populations;
scale up prevention of mother-to-child transmission services; and implement activities
targeting young women and girls. The GAC said that the new grants will:
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ensure continuity of services for patients on life-saving treatment including ARVs,
TB medicines and critical health products for opportunistic infections, and laboratory
reagents for clinical monitoring;
scale up services in high burden states;
establish new treatment sites and upgrade and strengthen diagnostic centers, including
procurement of GeneXpert machines and other laboratory equipment;
improve early infant diagnosis; and
invest in building resilient systems for health.
Ambitious TB notification targets have been established to respond to a threefold increase in
the estimated disease burden as reported in the 2012 TB prevalence survey.
During the protracted grant-making process, the Secretariat worked with the TB and HIV
PRs to incorporate into the program measures to address the historic risks and challenges
cited earlier in this article.
Dr Dauda Suleiman Dauda, Acting Chair of the CCM told GFO that the condition attached to
the grant regarding the recovery of funds owing from the 2011 audit would be met. Some of
the funds have been recovered, he said, and the CCM has approached the federal government
to recover the rest using its anti-graft agencies. “We cannot just allow some individuals make
the entire country suffer,” he said.
Information for this article comes from the December 2016 report of the Secretariat’s Grant
Approvals Committee to the Board (GF-B34-ER01). This document is not available on the
Fund’s website.
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3. NEWS: Prevention materials are still getting through
to the “uncontrolled areas” of Eastern Ukraine
Delivery of TB medicines is more problematic
Alliance is working with partner organizations
Tinatin Zardiashvili
16 December 2015
Operating in difficult and deteriorating conditions, the Alliance for Public Health (formerly
the International HIV/AIDS Alliance Ukraine), in cooperation with the Global Fund and the
World Health Organization, have managed to deliver a one-year supply of the rapid test kits
for HIV, STIs and hepatitis C to the uncontrolled regions of the Donbas area in Eastern
Ukraine – i.e. Donetsk and Lugansk.
They have also managed to deliver eight months’ worth of medical supplies (single syringes,
alcohol wipes, condoms and lubricants).
In 2014, the Global Fund and the Ukraine principal recipients established a health sub-cluster
group, which is coordinated by the WHO. Regular meetings are held involving all
international agencies operating in the country and the Ministry of Health. The sub-cluster is
coordinating and supporting the health programs operating in the uncontrolled regions.
Since the occupation of parts of Eastern Ukraine, the Alliance had been able to provide HIV
testing and prevention services for the people residing there. At the same time, the Alliance
had been able to continue supplying TB drugs for the treatment program run by TB centers in
Lugansk and Donetsk. All commodities were procured under existing programs financed by
the Global Fund.
However, the situation became more complicated in 2015 because of restrictions imposed by
the de-facto authorities in the uncontrolled regions. Governors of the occupied territories
introduced accreditation, application, and other systems covering all types of cargo delivered
to the region, including humanitarian aid. At the same time, the Ukrainian Government
established strict regulations requiring documenting deliveries to the territories it no longer
controls.
In these difficult conditions, the Alliance managed to deliver three shipments of prevention
commodities in 2015. Each of them required precise planning, obtaining of all necessary
permits from both sides, and intense co-ordination with the authorities and recipients of the
commodities. The last shipment was done in mid-November. While delivering the test kits, it
was very important to organize proper temperature conditions for their transportation. To do
so, a refrigerator lorry was specially rented by the Alliance.
According to Pavel Skala, associate director of policy and partnership at the Alliance:
“In light of the current epidemiologic situation and existing high risks of spreading
infections, it was extremely important to ensure that our beneficiaries have kept
access to prevention materials. Since the last delivery in July 2015, the situation has
significantly deteriorated, in terms of both administrative procedures and security.
Therefore, it is a success to know that our local partners have sufficient supply to last
until July 2016 and enough medical supplies of the test systems to last until the end of
2016.”
According to the Alliance, historically, the Eastern part of the country has had higher HIV
prevalence than the rest of the country, but through the efforts of programs supported by the
Global Fund, the epidemic in Eastern Ukraine had stabilized by 2013. However, as a result of
the current conflict, the epidemiological situation has significantly deteriorated.
Increased sex work has contributed to increasing cases of HIV and hepatitis C. In 2014, 3,000
new cases of HIV were registered in Donetsk, representing 27% of all new cases across the
country. In the first six months of 2015, 593 new cases of HIV were registered in Donetsk.
HIV prevalence among persons who inject drugs has increased from 26.5% to 34% in
Donetsk and from 3.2% to 7.3% in Lugansk. It has become difficult to get a handle on the
situation because there is no official surveillance data and internal migration is not controlled.
However, according to Alliance, the increase of HIV prevalence among soldiers and the
female population (mostly due to increased sex work) is already noticeable.
New border regulations have affected the work of Médecins sans Frontières and U.N.
agencies in Donbas. They do not have accreditation and, therefore, are not allowed to work in
the Eastern territories at the moment. MSF was a partner of Alliance Ukraine in delivering
TB medication. Now the Alliance is in the process of establishing new channels and
negotiating with potential new partners.
“Delivery of the prevention consumables and TB medicines are two different things,”
explained VitaliyVelikiy, head of the Alliance procurement and supply management team:
“We have our local partner NGOs which provide prevention services on the ground in
occupied part of Donbas, and they at the same time act as legal recipients of cargoes
with consumables from Alliance. But for TB medicines we need to have the legal
recipient (consignee) which is a medical institution and which can accurately register
distribution of the medicines to the patients. Previously we performed our deliveries
directly to so-called TB dispensaries, located in occupied territories, which have
been moved out of Ukrainian jurisdiction since December 2014. This is why after that
the only solution for us was to deliver medicines via partnering international
humanitarian organizations like MSF (delivery in July-August 2015 to Donetsk and
Lugansk). Meanwhile, since MSF has now lost its accreditation at the de-facto
authorities there, we are keen to find a new partner as soon as possible.”
At the moment, Alliance Ukraine is providing eight types of medicines for MDR-TB which
support treatment of 507 patients in Donetsk and 260 in Lugansk. The stock of TB-medicines
in these two areas is enough to last only to the end of 2015.
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4. NEWS: Among second batch of regional concept notes, a community
approach to treatment access in West Africa
Regional treatment observatory envisaged
Gemma Oberth
7 December 2015
While the world celebrates the recently announced achievement of 15.8 million people on
antiretroviral therapy, this progress has not been evenly felt. In April 2015, the International
Treatment Preparedness Coalition – West Africa (ITPC-WA) submitted an expression of
interest for a regional concept note which seeks to address disproportionally low treatment
access in West Africa (Figure 1). The EOI framed the urgent need to address barriers to
access, which make 90-90-90 a distant reality for the region. For example, in Liberia just
21% of people living with HIV are on treatment; in Guinea Bissau, just 19%.
Figure 1: Comparisons of Adult ART Coverage (UNAIDS, 2014)
The EOI was approved in June 2015 with a budget ceiling of $5 million. The goal is to
increase access to treatment in 11 West African countries: Benin, Côte d’Ivoire, Gambia,
Ghana, Guinea, Guinea Bissau, Liberia, Mali, Senegal, Sierra Leone, and Togo.
The proposed program would support the implementation of a regional community treatment
observatory, empowering networks of people living with HIV to systematically collect and
analyze qualitative and quantitative data on barriers to access. This may include documenting
prices and stock outs of medicines, as well as experiences at health facilities. “You don’t
need a PhD in epidemiology to do this,” says Solange Baptise, Director of Global Programs
and Advocacy at ITPC Global. “It’s led by communities and people living with HIV. It’s
what communities think should be measured.”
Data collected through the regional treatment observatory will then be used for targeted
advocacy at regional level, aimed at bodies like the West African Health Organisation and
the Economic Community of West African States.
The value-add of the regional approach is to standardize and centralize data which is
currently being collected through several existing community treatment observatories
operating at national and sub-regional levels. Examples include the Community Observatory
on Access to Health Services (OCASS), which covers Burkina Faso, Guinea, and Niger.
OCASS is led by RAME (Réseau Accès aux Médicaments Essentiels) and funded by the
French government’s 5% Initiative. Another existing observatory is in Sierra Leone, where
the national network of people living with HIV (NETHIPS) is implementing key populations
treatment observatories in high burden areas of the country. “Harmonizing treatment
observatories at the regional level is important,” says Sylvere Bukiki, Director of ITPC-WA.
“At the moment, community monitoring around treatment access is very fragmented and this
is hampering advocacy efforts in the region.”
In preparation for concept note submission on 1 February 2016 – the second and final
window for regional applications – ITPC-WA has convened a widely consultative
engagement process. Taking stock of lessons learned from the first round of regional concept
notes, which revealed the high cost of regional dialogue requirements, ITPC-WA employed
innovative consultation approaches which were both more inclusive and less expensive.
First, an online dialogue was held in November and December 2015, attracting 157 responses
from people in region on their priorities for the proposed program. The online dialogue
revealed a consensus around three main barriers to access in the region: inconsistent
availability of ART, poor quality of health services, and a lack of enabling legal and policy
environment. Based on these gaps, participants in the online consolation emphasized the
value of a regional watchdog over national implementation. Communities felt that the
regional approach to monitoring treatment access would improve the availability of data,
coordinate existing initiatives, and facilitate exchange on best practices and technical
assistance between countries.
Next, an in-person regional dialogue was held on 2 December in Harare, Zimbabwe, on the
margins of the 18th International Conference on AIDS and STIs in Africa (ICASA). By
allowing many participants who were already there for the conference to also engage in the
regional dialogue, this saved further resources and allowed for even wider participation.
During the in-person meeting, the conversation focused heavily on the World Health
Organization’s new ART guidelines, which recommend that ART should be initiated in
everyone living with HIV at any CD4 cell count. Participants discussed the feasibility of
implementing “test all, treat all” policies in their region. Reflecting on this issue, one
participant said “We do not have faith in the political will to achieve this. But if we don’t
have faith in our leaders, can we as communities do something to achieve this
recommendation?”
As the dialogue turned to issues of sustainability, a young man from Senegal said he had
confidence in the long-term viability of the program: “Many partners have started to
implement observatories. Some started with other partners, others just did their own
initiatives. I think this shows that the sustainability is there, because this is an existing
initiative. The need is just to centralize this information collection.”
With the release of UNAIDS’ 2015 World AIDS Day report, the importance of locationspecific information has never been more clear. All too often, global and regional averages
mask national and local level disparities. Investments and interventions must be able to
strategically target the right places with the right things. This is only possible with the right
data. “The idea is to document a regional state of affairs that informs the global conversation
about access to treatment,” says Christine Stegling, Executive Director of ITPC Global. With
a regional treatment observatory in West Africa, communities and people living with HIV
will be at the forefront of that conversation.
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5. NEWS: Aidspan finds gaps in the Global Fund’s response
to HIV/AIDS epidemic in children
Ann Ithibu
16 December 2015
According to a new report, children may still not be prioritized under the new funding model.
Released by Aidspan, the report highlights the results of an analysis of 22 concept notes
submitted to the Global Fund and grant agreements (usually referred to as grant confirmation
forms under the NFM) signed between the Global Fund and 16 principal recipients. The
report is available here (listed under Recent Reports).
In its Strategy 2012-2016: Investing for Impact, the Global Fund committed to strengthen
content relating to maternal, newborn, and child health (MNCH) in proposals. However this
analysis reveals that child-related interventions in relation to HIV may still be
underrepresented within HIV concept notes.
The study examined the inclusion of 47 key child- and adolescent-related interventions
within concept notes. The list of interventions came from a review of scientific papers and
guidelines on this topic. The interventions were classified into five broad elements:

prevention of mother to child transmission;

pediatric treatment, care and support;

adolescent prevention, treatment, care and support services (including the adolescent
key population groups);

laws and policies to reduce vulnerabilities and increase access to HIV services; and

addressing gender based violence.
Grant agreements were also examined for the inclusion of child-related indicators.
Representation of child-related interventions was generally low; 45% of the concept notes
contained less than 10 of the 47 interventions. Five percent contained none of the
interventions.
According to a recent report by UNICEF, the number of AIDS-related deaths among
adolescents has tripled over the last 15 years. Despite the large number of children
transitioning into adolescence without knowing their HIV status, less than 40% of the
concept notes in the study included provider-initiated HIV counseling and testing targeting
children in immunization clinics, outpatient clinics and pediatric wards.
According to UNICEF, a majority of adolescents have no access to prevention interventions.
This is consistent with the findings in this study where 27% of the concept notes reviewed
did not contain any of the adolescent key interventions. Interventions targeting adolescents in
the each of the areas of HIV testing and counseling, antiretroviral therapy, family planning,
and voluntary medical male circumcision were included in less than 30% of the concept
notes.
A review of grant agreements revealed that 87% had child-related indicators. However, a
majority of the indicators included children only as part of the broader age groups. Half of the
grant agreements had an indicator on provision of ART for pregnant women, while none had
indicators on distribution of condoms, family planning for women living with HIV, infant
feeding counseling or capacity building of health care workers.
It is not possible to determine from the concept notes and grant agreements the specific
budget amounts allocated to children. However, our analysis revealed that funding for crucial
interventions, particularly for the adolescents, was, in some instances, requested in the aboveallocation portion of the concept notes. These included promotion of youth friendly services
in health services; combating gender-based violence, early marriage, and intergenerational
and transactional sex; providing economic support to orphans and vulnerable children;
offering family planning counseling services; scaling up pediatric ART; and providing inand out-of-school youth programs.
(The above-allocation portion of the concept note contains interventions that are not covered
by the allocation to the country and that would only be financed if additional funding were to
become available.)
The Aidspan study revealed gaps in child HIV programs. Some of these gaps were
highlighted during the 2015 Global Fund partnership forums aimed at providing guidance
and input for the development of the Global Fund Strategy 2017-2022. The stakeholders
called for increased focus on gender, human rights and key populations including during
transition planning. They recommended more focus on gender issues, advocacy and support
for the introduction of laws that enhance the rights of women and girls.
The stakeholders also highlighted the need for quality disaggregated data and incentives to
motivate human rights and gender-based funding and also gender-specific interventions.
They also recommended the development of key performance indicators (KPIs) to measure
gender outcomes for women and girls. Finally, they said that gender-based violence should
be addressed through the concept notes and programming within the countries.
Aidspan comment:
As the Global Fund comes up with their new strategy 2017-2022, there is need for more
focus on children HIV programming. The Global Fund needs to push for more MNCH
content in the concept notes. Data is also required to assess the impact of Global Fund on
HIV in children. Countries should also use the opportunity provided in drafting concept notes
to scale up child-focused interventions.
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6. ANALYSIS: Global Fund promises a major effort to expand investment
in human rights programming
Under the NFM, guidance on including human rights in concept notes
has improved considerably
David Garmaise
16 December 2015
As far back as Round 10, applicants were asked to indicate how their proposals would help to
create an enabling policy and legal environment, and address issues of human rights related
to repressive laws and policies. However, with the advent of the new funding model, the
Global Fund has become more prescriptive in terms of what applicants should include in their
concept notes, and has provided considerably more guidance on how to address human rights
issues. Nevertheless, the Fund plans to step up its efforts to persuade countries to invest in
human rights programming.
The guidance is outlined in two key documents:


the Standard Concept Note Instructions that accompany the concept note templates;
and
an 18-page Core Human Rights Information Note on Human Rights, TB, Malaria and
HSS Grants (February 2014)
In addition, a 4-page Focus on Human Rights document was recently released. It summarizes
the work undertaken to date, and outlines some new directions.
In their concept notes, applicants are required to identify human rights barriers to health
services and are strongly encouraged to include seven practical programs to address the
barriers:




human rights and ethics training of health care workers;
stigma reduction;
sensitization of police and judges;
legal and human rights literacy;



legal services;
empowerment of women and girls; and
law reform.
In its Focus on Human Rights document, the Global Fund describes three grants that contain
some of these programs: (a) a TB/HIV grant in Botswana that provides human rights training
for police and judges so they apply the law in a way that supports access to health services;
(b) human rights and literacy training for peer educators and community-based organizations
as part of a push to expand testing and treatment for TB and HIV in Malawi; and (c) a
program in South Sudan to train health care workers to respond instances of gender-based
violence.
However, as expressed in Mark Dybul’s recent report
to the Board (see GFO article), the Global Fund is
concerned that, overall, investment in these programs
remains too small, and too few countries have included
them. GFO has been informed that moving forward,
the Global Fund will therefore make a major effort to
expand investment in these programs.
In addition to funding programs that remove human
rights barriers to access, the Global Fund has
established minimum human rights standards that
implementers commit to when they sign grants. The
standards are as follows:





non-discriminatory access to services for all,
including people in detention;
employing only scientifically sound and
approved medicines or medical practices;
not employing methods that constitute torture
or that are cruel, inhuman, or degrading;
respecting and protecting informed consent,
confidentiality and the right to privacy
concerning medical testing, treatment, or health
services rendered; and
avoiding medical detention and involuntary
isolation, to be used only as a last resort.
The facts:
• In the hardest-hit countries, girls
account for more than 80% of all
new HIV infections among
adolescents.
• In parts of Africa, Asia, the
Caribbean, Eastern Europe, and
Latin America, HIV rates among men
who have sex with men, transgender
people, sex workers, people who
inject drugs and prisoners can be as
high as 30-50%.
• In many places, police use
condoms as evidence of sex work,
or arrest people who inject drugs
near health centers that provide
harm reduction services, driving
people away from the prevention
and care they need.
• Lesbian, gay, bisexual and
transgender people are criminalized
in more than 75 countries.
• In many countries, punitive legal
frameworks limit access to TB
services for migrants.
Source: Focus on Human Rights
Under a human rights complaints procedure established by the Global Fund, individuals and
groups can submit a complaint to the Office of the Inspector General if they believe that any
of the human rights standards above have been violated by an implementer.
Ideally, human rights programs such as those described above should be included in national
strategic plans. Where this has not been done, the Global Funds says that the country
dialogue offers a second opportunity to consult with key populations, people living with the
diseases and human rights experts. The Core Human Rights Information Note includes a long
list of questions that can be posed during the country dialogue to identify human rights
barriers to accessing services.
The Focus on Human Rights document provides the example of Belize, where the significant
engagement of key populations in the country dialogue resulted in over 10% of the $3.5
funding award being invested in programs to increase access to justice; train health care
professionals on human rights and HIV; support communities to monitor human rights
related to health; and build the institutional capacity of a transgender network in its infancy.
Within the Community, Rights and Gender unit in the Secretariat, there are two staff persons
on the human rights team – Ralf Jürgens, who joined the Global Fund in May 2015 as Senior
Coordinator, Human Rights; and Hyeyoung Lim.
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7. NEWS: Database of civil society organizations in Burkina Faso
boosts the community response
Database fed into the development of an HSS concept note
Bertrand Kampoer
16 December 2015
A database of civil society organizations in Burkina Faso was instrumental in developing the
community component of a concept note on health systems strengthening, according to
Simon Kaboré, executive director of RAME (Réseau pour l’Accès aux Médicaments
Essentiels) and member of the country coordinating mechanism.
In 2012, PADS (Programme d’Appui au Développement Sanitaire), an entity of the Ministry
of Health and a principal recipient of a Global Fund grant, ordered a mapping of all the
community stakeholders involved in the health system in Burkina Faso in order to update a
database of NGOs and associations. In 2008, a similar work was done by PAMAC
(Programme d’Appui au Monde Associatif et Communautaire). A review of the existing
databases from DEP (Direction des Etudes et de la Planification and DSONG (Direction du
Suivi des Organisations Non Gouvernementales) was also used.
This latest updating of the database was completed in 2014.
An invaluable source of information, the database showed the type of activities implemented
by associations, where their interventions took place, who the beneficiaries were, and what
tools the associations had at their disposal. It also included the challenges they met as well as
suggestions on improving how activities are coordinated and on what monitoring and
evaluation was required in order to make their work more effective and visible.
Through the database, several weaknesses were identified with respect to the coordination of
interventions and how they were structured. The three diseases were not covered equally:
According to the database, for example, only 9.3% of health centers provided TB treatment.
This information led to a decision to include in the concept note activities to reinforce the
community response in the health sector – activities related to service delivery (such as
providing support to patients, community monitoring and awareness raising) as well as to
institutional strengthening (such as the payment of rent, and money for salaries and
computers).
Challenges in creating the database
This database was not easy to do. PADS had to recruit a team of consultants to lead the
process, including a public health doctor (who was the head of mission), a community
specialist and an engineer specialized in statistics.
The objectives of the team were to do a document review of all NGOs and associations
involved in the community health sector; establish a methodology for additional research;
develop data collection tools; and put together a work plan. Then, they had to collect the data
in the field, design the mapping and the database, and organize a workshop to present the
results.
This process was overseen by the DGS (Direction Générale de la Santé) whose role was to
provide recommendations at each step of the process (methodology, work plan, data
collection, field visits, research, interviews with different groups, preliminary report). The
project lasted 60 days.
One of the challenges was the fact that the existing data were incomplete or contained
outdated information. Several associations did not manage to provide all the information
requested in the form. The missing information had to do with equipment (vehicles,
computers) and finances (amounts and sources). Some networks of associations did not have
this type of information about their members; those that did had not updated the information.
The database unveiled various problems affecting the community work. The planned
activities did not always correspond to the profile for community agents which Burkina Faso
adopted in 2014. There was a lack of motivation and a lack of a common approach for
community interventions.
Solutions were proposed in the concept note, including developing an orientation guide for
community health agents; organizing training sessions; making equipment and supplies
available; monitoring the activities implemented by community groups; organizing strategic
information workshops for elected officials and local leaders; organizing quarterly
monitoring and coordination meetings; and providing institutional support to the associations.
Acknowledging the challenges in collecting information from the associations, Simon Kaboré
recommends a better collaboration in future with CORAB (Coalition des Réseaux et
Associations du Burkina Faso) – the national network of associations – and with technical
and financial partners.
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8. NEWS: Funding in the amount of $224 million approved in November
For the first time, external funding has been used
to fund an initiative on the UQD register
David Garmaise
7 December 2015
In November 2015, the Global Fund Board approved $224 million in funding for 22 grants
emanating from concept notes submitted by 14 countries and one regional organization. The
Board was acting on recommendations from the Grant Approvals Committee and the
Technical Review Panel.
Included in the $224 million was $16 million in incentive funding. In addition, the Fund
placed interventions worth $40 million in the registry of unfunded quality demand. See the
table for details.
Most of the funding approvals for individual component were for relatively small amounts.
Benin, with three components spanning four grants, received $70 million, far more than any
other country. Belarus was second with $26 million. See the table for details.
In addition to the $224 million, the Board approved $31.3 million for Zimbabwe’s HIV
component, made up of $25.3 million in incentive funding, and $6.2 million specifically to
support the provision of pediatric ARVs and related initiatives. As an early NFM applicant,
Zimbabwe did not have an opportunity to compete for incentive funding. Thus, the country
coordinating mechanism was allowed to submit a request for funds specifically from the
incentive funding envelope.
The pediatric initiatives are being funded by the Children’s Investment Fund Foundation. The
initiatives the CIFF will support were on the register of unfunded quality demand. This
represents the first time that an initiative from the UQD register has been funded with money
from a source external to the Global Fund.
Because of perceived risks, the funding award to Jamaica was accompanied by a special
condition in the grant confirmation form requiring the submission of a detailed annual report
on compliance with essential health product absorption commitments, including antiretroviral
expenditures and management.
The Board also approved exceptions to existing policies to make it easier to manage grants in
challenging operating environments in Iraq, Palestine, Syria and Yemen (see GFO article.)
Table: Funding for country grants approved by the Global Fund, November 2015 ($ million)
Country
(component)
Grant name
Armenia (HIV)
ARM-H-MOH
ARM-H-MEA
Azerbaijan (HIV)
Belarus (HIV)
Principal
recipient
Ministry of Health
Mission East
AZE-H-MOH
Ministry of Health
BLR-HRSPCMT
Rep. Scientific
Practical
Center of Medical
Technology
Approved Funding
Existing
New
Total
Of
which,
incentive
funding
Added to
UQD
register
0.7 m
3.2 m
3.9 m
NIL
5.0 m
NIL
1.7 m
1.7 m
3.6 m
6.3 m
9.9 m
NIL
NIL
1.7 m
12.0 m
13.7 m
NIL
0.2 m
0.4 m
11.9 m
12.3 m
NIL
NIL
23.0 m
NIL
23.0 m
NIL
NIL
2.4 m
5.3 m
7.7 m
8.5 m
25.3 m
33.5 m
9.0 m
NIL
1.5 m
4.9 m
6.4 m
0.4 m
NIL
9.5 m
4.4 m
13.9 m
NIL
20.9 m
0.6 m
7.8 m
8.4 m
NIL
NIL
Belarus (TB)
BLR-TRSPCMT
Benin (HIV)
BEN-HBENPLNS
Ministry of Health
BEN-HPlanBen
Plan Benin
BEN-M-PNLP
Ministry of Health
BEN-TPNTUB
Ministry of Health
CIV-M-SCI
Save the Children
Dominican Rep.
(TB)
DOM-TMSPAS
Ministry of Health
El Salvador (TB)
SLV-T-MOH
Ministry of Health
0.2 m
9.8 m
10.0 m
NIL
NIL
GAM-T-NLTP
Ministry of Health
NIL
3.9 m
3.9 m
NIL
NIL
GMB-T-NLTP
Min. of Health and
Social Welfare
1.3 m
6.7 m
8.0 m
0.4 m
NIL
Regional (HIV)
QRA-HHIVOS
ICW Latina
NIL
4.3 m
4.3 m
NIL
NIL
Jamaica (HIV)
JAM-H-MOH
Ministry of Health
0.3 m
14.9 m
15.2 m
NIL
NIL
Paraguay (TB)
PRY-T-AVA
Alter Vida
0.4 m
5.6 m
6.0 m
NIL
NIL
Tajikistan (TB)
TJK-T-HOPE
Project HOPE
4.7 m
8.6 m
13.3 m
TJK-T-RCTC
Republican Center of
TB Control
NIL
NIL
NIL
4.7 m
4.7 m
Timor-Leste
(TB)
TLS-708-G04T
Ministry of Health
0.6 m
4.2 m
4.8 m
0.9 m
NIL
Timor-Leste
(HIV)
TLS-H-MOH
Ministry of Health
3.9 m
0.4 m
4.3 m
NIL
NIL
2.8 m
12.5 m
15.3 m
4.8 m
13.5 m
66.1 m
158.1 m
224.2 m
15.5 m
39.6 m
Benin (Malaria)
Benin (TB)
Côte d’Ivoire
(Malaria)
Gabon (TB)
Gambia (TB)
Vietnam
(Malaria)
TOTALS
VNM-MNIMPE
National Institute of
Malariology, Parasitology &
Entomology
The grants to Benin, Côte d’Ivoire and Gabon were in euros which we converted to dollars at the rate of 1.0720.
Discrepancies in totals due to rounding.
Regional grant
The strategic focus of the regional grant to be administered by ICW (International
Community of Women Living with HIV/AIDS) Latina is “to position women living with
HIV in 11 Latin American countries as a key population in the effort to contain and reverse
HIV, and empower them as actors who are trained to defend their human rights in their
communities.”
Included in the program’s strategies are (a) advocacy at the regional and national level,
including the development of an online tool to track regulatory and policy frameworks related
to the rights of women living with HIV; and (b) capacity building of women living with HIV.
The latter will entail development of a methodological toolkit that focuses on gender-based
violence, human rights, and exercise of citizenship; and transformational leadership
workshops for the ICW Latina network.
Funding for key populations and harm reduction in HIV awards
Services for key populations were contained in eight HIV components. Specifically, services
for men who have sex with men were included in four components; for persons who inject
drugs in four; for sex workers in three; for people in prisons in three; and for transgender
people in two.
Armenia plans to provide methadone substitution both inside and outside of prisons. In
Azerbaijan, needle exchange programs will be scaled up. In Belarus, opioid substitution
therapy and needle exchange are among the services to be provided.
Among the strategies included in the HIV grants to Benin are (a) programs addressing gender
violence and removing legal barriers through policy and legal advocacy; and (b) providing
psychological, legal, and microcredit economic support to people living with HIV, orphans
and vulnerable children, and key populations.
One of the strategies identified in the report is innovative approaches to reaching young
women and girls.
Funding for malaria: highlights
The Board approved minor additional funding for two malaria components that had already
been awarded funding under the NFM: Bangladesh and Côte d’Ivoire. For one Bangladesh
grant, BGD-M-BRAC, the approved grant budget was raised from $9.7 million to $9.8
million. For a second grant from that country, BGD-M-NMCP, the approved budget went
from $15.7 million to $15.9 million. The GAC said that the additional amounts are within the
allocations, and represent the reinvestment of undisbursed and unused cash funds from
Round 10 grants that were not included in the total budget when the Board approved funding
for the Bangladesh malaria grants in June 2015. According to the GAC, the CCM has
requested that the additional amounts be invested in initiatives on the UQD register.
For Côte d’Ivoire, the approved budget for grant CIV-M-MOH was increased from $83.5
billion to $88.4 billion. GFO is planning to provide additional details on the increase in a
separate article.
The GAC report noted that in Benin, spot checks of a sample of 140 vendors in markets and
streets revealed that up to 50% are selling counterfeit or substandard artemisinin combination
therapies. Given that a high proportion of the population obtains services from the private
sector, Benin will use efficiencies identified in the budget for the malaria grant during grantmaking to support current efforts to address this problem involving Benin’s drug regulatory
agency, and partners such as USAID and the (U.S.) President’s Malaria Initiative.
With respect to malaria grant for Vietnam, the Global Fund will phase out contributions to
salary incentives by the end of 2015, and will support only a travel allowances for village
health workers, which is considered critical for active case finding efforts.
Funding for TB: highlights
With respect to the TB funding for Gabon, a key strategy for providing services to key
populations involves the use of community agents to provide patient support, including
patient follow-up, psycho-social services and peer training for other community agents.
Some of the funding awarded to the Gambia TB component will be used for programs to
retain and build the capacities of health workers and technicians.
Sustainability
The GAC report briefly described steps that were taken in nine of the 22 country grants to
strengthen the sustainability of programs currently supported by the Global Fund (see GFO
article).
Information for this article comes from the November 2016 report of the Secretariat’s Grant
Approvals Committee to the Board (GF-B33-ER18). This document is not available on the
Fund’s website.
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9. NEWS: Special arrangements established for funding applications
from four Middle East countries and territories
David Garmaise
7 December 2015
The Global Fund Board has waived certain requirements for processing HIV and TB funding
applications from Iraq, Palestine, Syria, and Yemen because of the current political context
and challenging operating environments in these countries and territories. The requirements
that have been waived relate to country coordinating mechanism eligibility, counterpart
financing, and willingness to pay.
The Fund said that Iraq, Syria, and Yemen are unable to develop robust national strategic
plans that are reflective of the actual situation. Nor can they fully address HIV and TB
program needs or provide services for those living in or displaced by conflict zones.
The Secretariat plans to develop funding proposals to manage grants for these countries
through a combined management platform that will rely on existing health clusters. These are
centers where the World Health Organization and other development agencies work together
to improve the effectiveness of of humanitarian health action. Formal health clusters exist in
Yemen and Iraq, and informal ones in Syria and Palestine.
The Secretariat believes that having an integrated grant management platform located in one
center in close proximity to the proposed countries will enhance the effectiveness of the
Fund’s investments. This approach should enable the delivery of life-saving services to
populations where they are located, which is changing on a constant basis for a large number
of people.
The Global Fund hopes that the health clusters will provide the governance and
accountability that the CCMs are not able to provide.
The details concerning how these platforms will work will be described when the relevant
funding proposals are submitted to the Board for approval.
Given the protracted crisis in Palestine, it has been included in this decision so that it may
benefit from the efficiencies that may be generated from the combined grant management
platform.
Information for this article comes from the November 2016 report of the Secretariat’s Grant
Approvals Committee to the Board (GF-B33-ER18). This document is not available on the
Fund’s website.
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
10. NEWS: Major focus on sustainability in November funding approvals
Even low-income countries are affected
David Garmaise
7 December 2015
Sustainability was a prominent theme in the November report of the Grant Approvals
Committee to the Board. Ten of the 22 grants recommended for approval had already taken
some steps towards sustainability or included measures in their proposed programs. Three of
the 10 grants were from low income countries.
For Armenia, an upper lower-middle-income country, the funding awarded to its two HIV
grants was conditional on the development of a sustainability plan by 30 June 2016. The plan
will call for increasing HIV-related expenditures during the next three years and having the
government take over the costs of the full HIV program after the Global Fund grant ends in
2018. The government has already committed to gradually increasing financing for some
activities, such as providing antiretrovirals for 200 patients in 2017, 300 patients in 2018 and
methadone procurement from 2018 on.
Total domestic financial commitments for the HIV program in Belarus, an upper-middleincome country, amounted to $52 million, which represented 80% of total resources available
for the next implementation period. “Sustainability is at the core of this grant,” the GAC said.
A national principal recipient is taking over from the UNDP and the government is
expanding its commitment to fund various program areas, including HIV prevention services,
ARV procurement, patient adherence support, and HIV testing. “The grant is regarded by all
national stakeholders as a transition step toward government ownership,” the GAC said.
Furthermore, the grant included a condition on development of a sustainability plan for
Global Fund funded activities by the end of 2016.
Sustainability is also central to the Belarus TB grant, where total domestic financial
commitments amounted to $190 million, which represented 94% of total resources available
for the next implementation period. This grant is also considered a transition step toward
government ownership with the government expanding its commitment to fund various
activities, including patient adherence support, procurement of first-line and most second-line
TB drugs, and laboratory work. The development of a sustainability plan for Global Fund
funded activities by the end of 2016 is a condition of this grant as well.
Regarding the malaria grant to Benin, a low-income country, the national malaria program is
taking over as PR from the UNDP. Capacity-building and training activities are included in
the grant to support sustainability of the program.
According to the GAC, Côte d’Ivoire, a lower-LMI country whose malaria grant was
recommended for approved, has taken steps to ensure financial sustainability, including
initiatives with potential to increase revenues for the health sector, such as the universal
health insurance bill passed in March 2014, and introduction of innovative financing
mechanisms, such as taxes on tobacco and air travel as well as Debt2Health.
With respect to a TB grant to the Dominican Republic, a UMI country, total domestic
financial commitments to the TB program amounted to $67 million, which represented 89%
of total resources available for the next implementation period and a 21% increase from the
previous implementation period. The Dominican Republic has taken several steps toward
sustainability, including absorbing costs of human resources and second-line TB drugs from
previous Global Fund–financed programs.
One of the grants recommended for funding was a TB grant to El Salvador, an upper-LMI
country. Total domestic financial commitments to the TB program amounted to
$24.5 million, which represented 71% of total resources available for the next
implementation period. The GAC said that the new national strategic plan will increase the
sustainability of the national TB response by gradually shifting financial responsibility from
the Global Fund grant to the government, and implementing interventions through costeffective health and community systems. Government contributions are largely focused on
human resource costs, to support the country’s TB response strategy in detecting more
respiratory symptoms and administering TB treatment in the community and health facilities.
Gambia is an LI country whose TB grant was recommended for funding. The 2015-2020
national health sector plan aims to use tax-base and non-tax base approaches to increase
financing for health care, including advocacy for innovative financing and instituting a 3%
levy on tobacco and tobacco products, alcohol and other products hazardous to one’s health.
A financial sustainability plan will be developed as well as a resource mobilization plan, to
improve revenues to the health sector.
In the case of an HIV grant to Jamaica, a UMI country, total domestic financial
commitments to the HIV program amounted to $54 million, which represented 54% of total
resources available for the next implementation period. The country has also committed to
spending an additional $6 million. The government will progressively absorb costs related to
treatment and clinical diagnostics, assuming the full cost of ARVs by the end of the
implementation period. Investment from the Global Fund and other partners will help to build
capacity and develop plans for sustainability.
Finally, concerning the TB grant to Tajikistan, another LI country, total domestic financial
commitments amounted to $16 million, which represented 27% of total resources available
for the next implementation period. The GAC said that the government has taken some
constructive steps towards the sustainability of TB services in the country, including
developing a funding sustainability plan through which the country will take over 100% of
financing for first-line drugs by the end of 2017. Additionally, the government will encourage
and motivate local public administrations to engage in developing solutions for effective
adherence support to TB patients, which will enhance program sustainability and government
ownership.
All of the grants recommended for funding were approved by the Global Fund Board in
November.
Information for this article comes from the November 2016 report of the Secretariat’s Grant
Approvals Committee to the Board (GF-B33-ER18). This document is not available on the
Fund’s website.
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11. NEWS: In brief
Aidspan staff
8 December 2015
New global fund to fight malaria and other tropical diseases
The U.K. and the Gates Foundation have announced they will work together on a new
$1 billion Ross Fund to support the global fight against malaria and other infectious diseases.
The fund is named after Sir Ronald Ross, the first ever British Nobel Laureate who was
recognised for his discovery that mosquitoes transmit malaria. The Ross Fund will support
research and development as well as in-country programs.
In a commentary in the Center for Global Development’s Global Health Policy Blog,
Amanda Glassman and Andrew Rogerson questioned the need for yet another health fund. “If
the UK and Gates signal that other mechanisms will work better than the Global Fund to
address malaria, just ahead of a replenishment year, global health will be headed in the wrong
direction, a direction of inefficiency and redundancy,” they wrote. “Reform of our existing
Global Fund rather than creation of yet another new Fund is the answer.”
CSOs in Malawi organize for greater impact
The Malawi Network of Religious Leaders Living with or Personally Affected by HIV/AIDS
(MANERELA+) organized several meetings with other CSOs in Malawi to talk about their
concerns and to develop a common agenda to influence the development of national plans
for HIV. The network lobbied successfully for the appointment of a different principal
recipient. And they succeeded in increasing the budget for community systems strengthening
from below $1 million to over $10 million.
There were other achievements as well. The story is told on the ITPC Global website here.
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12. ANNOUNCEMENT: GIZ extends deadline for applications
for technical assistance in its main program areas
Aidspan staff
11 December 2015
The GIZ BACKUP Health initiative has extended to 31 December 2015 the deadline for
applications for technical assistance from its three new program areas: country coordinating
mechanisms, health systems strengthening, and grant management. The original deadline was
15 December.
Among the types of project GIZ hopes to fund are:


capacity development of civil society organizations to strengthen their role in country
coordinating mechanisms;
support for principal recipients to identify risks and develop risk mitigation plans;



support for the development of comprehensive approach to organizational
development;
support for conducting needs analyses for HSS activities in grants, and for planning of
HSS interventions during concept note development; and
assistance in capacity development of civil society PRs to monitor their grants and
manage their SRs.
See the GFO article on this initiative published in October. The article contains a list of
countries eligible to apply for each program area.
Guidelines and application forms can be accessed here.
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This is issue #277 of the GLOBAL FUND OBSERVER (GFO) Newsletter. Please send all
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