The request has a strong focus on improving quality of care
On 20 March 2017, Zimbabwe submitted a TB/HIV funding request to the Global Fund for $628.9 million. This includes an allocation request for $431.9 million and a prioritized above allocation request (PAAR) of $197 million. A separate funding request for malaria was submitted on the same day for $51.7 million.
Zimbabwe's total allocation for the three diseases - nearly $484 million - is one of the largest allocations that any country received from the Global Fund for the 2017-2019 cycle. Only Nigeria, Tanzania, Congo (DR), Mozambique and India were allocated more.
The country submitted a funding request for full review, based on the Global Fund's new differentiated application process.
Zimbabwe's TB/HIV funding request centers on three main themes, which are stated up front in the narrative: enhancing integration, focusing on locations and populations at heightened risk, and improving quality of care. The need to improve quality of care was a key finding from the recent Office of the Inspector General (OIG) audit of Global Fund grants to Zimbabwe.
On the first theme - integration - the funding request prioritizes a host of TB/HIV collaborative activities, including "one-stop-shop" centers that offer multiple services under one roof, a new blended learning curriculum for training health care workers, and ongoing joint-planning between the two disease programs. The request also proposes using community-level platforms on reproductive and maternal health as entry points for preventing HIV transmission to infants and linking children exposed to TB to appropriate preventive therapy.
It is relevant that this is Zimbabwe's first integrated TB/HIV funding request. As an early applicant to the new funding model (NFM) in 2013, the country submitted single disease component requests for HIV and TB, before integrated funding requests were required by the Fund (for some countries).
It is also the first time Zimbabwe has integrated a request for cross-cutting activities to strengthen resilient and sustainable systems for health (RSSH), bolstering investments across HIV, TB, malaria and maternal health. The proposed RSSH interventions focus on supporting human resources for health, improving integrated sample transportation for laboratory tests, and expanding coverage of the electronic patient monitoring system.
On the second theme - focusing on locations and populations at heightened risk - there is clear emphasis on key and vulnerable populations in the funding request, especially in a context where little money is available for programmatic activities. About 70% of Zimbabwe's allocation has to be dedicated to the procurement of essential medicines and health products, and a further 20% has to go towards retaining critical human resources for health and program management.
Some people feel that relying on the Global Fund to fill such significant gaps is not a sustainable solution for Zimbabwe. "The country needs to push further for domestic financing, especially from the National AIDS Trust Fund, to ensure that our medicines are financed from domestic sources" says Donald Tobaiwa, a member of Zimbabwe's country coordinating mechanism (CCM) and Chair of its TB sub-committee. "We need to start to transition from such high donor dependency."
Zimbabwe's National AIDS Trust Fund was set up in 1999 as a 3% tax on income and corporate revenue. The Trust Fund has raised more than $200 million since its inception, currently contributing about $30 million a year to the country's AIDS response. The proceeds from the trust fund more than satisfy Zimbabwe's co-financing requirements.
Despite the squeeze on the Global Fund allocation to fill critical commodity gaps, the amounts requested for HIV prevention programs among adolescent girls and young women (AGYW), sex workers and men who have sex with men (MSM) still represent a near seven-fold increase compared to Zimbabwe's current grant.
There is also significant funding requested for targeted mobile TB screening among TB key populations, including miners, prisoners, children and migrant workers. The funding request states that this is reflective of the country's plans for rapid and intensified scale-up of services to address high disease burden among these groups. TB key populations in Zimbabwe have a 14-fold risk of contracting TB. HIV prevalence is around 57.1% among sex workers and 23.5% among MSM, far greater than the 13.8% among the general adult population. Young women aged 20-24 have HIV prevalence nearly three times greater than their male peers.
The programs for AGYW and key populations are highly geographically targeted, aiming to increase impact by saturating areas where the need is greatest. The interventions for AGYW are focused on just four high-burden districts. Interventions for sex workers are prioritized in the six major cities were sex workers congregate (termed "hot spot clusters") as well as in four border towns where truck drivers, artisanal miners and migrant workers are common clients.
As Zimbabwe is eligible for catalytic investments for AGYW and key populations, the country submitted an additional request for $18 million in matching funds, on top of its allocation amount.
The matching funds request proposes further "layering" of interventions for the same cohort of AGYW reached by the allocation funding, providing sanitary wear to support keeping girls in school and setting up four district-level one-stop centres for AGYW who are survivors of gender-based violence. These are key priorities that emerged from the women's sector during the country dialogue.
For key populations, the matching funds aim to scale up services through establishing additional fixed and mobile sites and supporting wider outreach with a greater number of trained peer-educators.
The country also requested matching funds for establishing a key populations Technical Support Unit (TSU), modelled after the Kenyan example. The TSU will provide short-term technical assistance and long-term capacity building for key populations networks and women's organizations, as well as support the Ministry of Health and the National AIDS Council to improve its ability to program for key populations.
Lastly, the theme of improving quality of care is perhaps the most central throughout the request. The request proposes an incentive-based retention scheme for health workers in facilities across the country, employing a pay-for-performance model that the country's National Health Strategy identifies as a strategic approach for maximizing impact. Aidspan has previously reported that the Global Fund desires to wind-down the practice of funding salary incentives for health workers and other Global Fund program staff, but in a country like Zimbabwe these investments are deemed vital for retaining key staff and improving quality of service delivery
"This was one of the most consultative processes we have ever undertaken to develop a Global Fund proposal," said Oscar Mundida, the Coordinator for Zimbabwe's CCM. "We had an open-door policy during the draft development, never turning away anyone who wanted to contribute." The resulting writing team was made up of more than 130 members.
That said, there were challenges with the process which some felt was too focused on treatment interventions at the expense of other activities. Tobaiwa raised concerns that if the country does not also program for demand generation, case finding and adherence activities, then investments in HIV and TB treatment will not be optimized and medicines will sit on shelves. "If we continue to prioritize medicines and not balanced demand, who will pay for the medicines that will expire?" he asked.
Prioritization within a country's allocation is often one of the most challenging parts of developing funding requests to the Global Fund.
The Technical Review Panel (TRP) is scheduled to sit from 23 April to 2 May to review funding requests submitted in the 20 March window. A response from the TRP on Zimbabwe's request is anticipated in mid-May, approximately ten days after TRP review.
Gemma Oberth was the lead consultant for Zimbabwe's TB/HIV funding request. Her work on the funding request was in her capacity as an independent consultant.