Among the grants approved by the Board in December were HIV, TB/HIV and malaria grants for Burkina Faso. This article provides a summary of the comments of the Technical Review Panel (TRP) and the Grant Approvals Committee (GAC) on all three grants.
See Table 1 for information on the grants and their principal recipients (PRs).
Table 1: New 2017-2019 grants to Burkina Faso
Component Grant name Principal recipient Budget ceiling
HIV BFA-H-SPCNLS Secrétariat Permanent du Conseil National de Lutte contre le Sida et les IST 32.1 m
TB/HIV BFA-C-IPC Initiative Privée et Communautaire contre le VIH/SIDA 7.0 m
Malaria BFA-M-PADS Programme d'Appui au Développement Sanitaire 84.6 m
When Burkina Faso was informed of its allocation for 2017-2019, the indicative program split was as follows:
HIV -- € 32,757,331
TB -- € 6,237,700
Malaria -- € 89,228,899
Total: € 128,223,920
The final, approved program split was a little different:
HIV -- € 38,149,415
TB -- € 8,011,196
Malaria -- € 82,063,309
Total: € 128,223,920
The Board also approved € 1.7 million in matching funds for data systems, generation and use.
The Burkina Faso malaria program aims to reduce malaria mortality to close to zero by 2020 through vector control and malaria case management support; to achieve universal coverage of diagnostic testing; and to provide treatment to 100% of confirmed cases in public and private health facilities, as well as at community level. The program includes the distribution of 12,174,202 long-lasting insecticidal nets (LLINs) through a 2019 mass campaign and routine distribution, to cover 100% of pregnant women and children under five. Approximately one-third of the grant comprises investments for resilient and sustainable systems for health (RSSH), focused on interventions to strengthen procurement and the supply chain system, the health management information system, community interventions and program management.
There was a separate HSS grant from the 2014-2016 allocations but because of poor performance of the grant, the health systems activities are being combined with the new malaria grant. Commenting on the low absorption rate of the HSS grant, the GAC said that Burkina Faso had worked hard to overcome absorption roadblocks and may have had one of the best absorption levels in West and Central Africa for 2014-2016.
The proposed program also calls for intensified efforts to address human rights and gender-related barriers to services, particularly among the most vulnerable, including refugees, internally displaced people (IDP) (due to flooding), street children in big cities, internal and external migrants, nomadic herders and gold diggers.
Issues and concerns
In its review of the funding request, the TRP identified several issues which, it said, should be dealt with during grant-making and grant implementation. Some examples are listed below:
Gender. The TRP expressed concern about cultural and social restrictions on women's mobility, as well as high levels of domestic and sexual violence against women and girls. The TRP said that systemic and structural barriers include gender inequality, lack of education, low access to employment opportunities and early marriage. It said that the barriers constrain the access of women and girls to vital health services. The TRP recommended intensifying efforts to empower women and girls so they can be more in control of their own and their family's health.
The TRP noted that the community health workers (CHWs) program is an important mechanism to reach women and girls, but that there was no information in the funding request on the gender breakdown of CHWs. Given the gender constraints in the country, the TRP said that it is concerned that if the majority of CHWs are male, women and girls will not fully benefit from community-level services.
The TRP said that it was concerned about the cultural and social restrictions on women's mobility, and high levels of domestic and sexual violence against women and girls. Systematic and structural barriers include gender inequality, lack of education, low access to employment opportunities and early marriage. These are exacerbated by poor economic empowerment. The TRP asked that the CCM provide a plan for assessing gender barriers to malaria diagnosis and treatment, and design interventions to reduce those barriers.
This issue was partially addressed during grant-making when the CCM added a few interventions to the proposed program to address gender barriers. However, the full plan requested by the TRP will be developed only after a gender access study is conducted.
Health systems. The TRP noted that whereas the existing malaria grant had a B1 rating, the existing HSS grant was rated only C. Of the eight targets for the HSS grant, only one was achieved adequately. The others showed poor performance due to difficulties encountered in the implementation of the grant, particularly with regards to community-based system strengthening. As a result, Burkina Faso proposed to consolidate its HSS activities with the new malaria grant, and to select a sub-recipient (SR) to manage the community component. The TRP requested some clarifications, which were provided during grant-making. In addition, the CCM reviewed the program split and decided to add € 800,000 to the malaria component to help cover health systems activities.
LLINs and insecticide resistance. The GAC said that most of the TRP's recommendations from its review of Burkina Faso's 2014 malaria funding request were appropriately addressed, except for one: The country committed to doing insecticide resistance monitoring and LLIN durability testing, but neither had yet been implemented. This issue was discussed and, hopefully, resolved during grant-making: The CCM provided a plan with clear activities and a budget.
HIV AND TB/HIV
The GAC noted the very ambitious targets of reaching 93,421 adults and children infected with HIV on ART in 2020 (from 57,157 in 2016), as well as increasing the percentage of pregnant women on ART to 95% in 2020 from 88% in 2016. However, the GAC expressed concerned about the slow up-take of pediatric HIV treatment. The Secretariat clarified that an emergency plan is being put in place in order to catch up with the 90-90-90 targets and to mitigate the possibility of not achieving the pediatric HIV treatment targets.
The GAC also noted that in line with the epidemic profile of the country, Global Fund-supported programs also invest € 6.9 million in a community component focusing on supporting key populations -- including men who have sex with men (MSM), sex workers, and prisoners -- with the aim of reaching 80% coverage with HIV prevention packages.
The GAC encouraged additional emphasis on TB to ensure continued progress towards addressing the problem of low TB case detection. The GAC also noted challenges in addressing multidrug-resistant TB (MDR-TB).
TRP comments on HIV
The TRP said that Burkina Faso is making progress on key interventions such as screening for HIV in antenatal care settings and linking women to treatment. However, the TRP said, there are several areas that require strengthening, including early infant diagnosis and enrolment of infected infants into treatment; the prevention and care continuum for key populations; and addressing structural human rights and gender barriers to care.
The TRP noted that Burkina Faso has planned a number of studies and a review of program strategy and guidelines during the course of 2017 and 2018 that have the potential to inform a redesign of the program and that, therefore, may call for a reprogramming request.
Issues and concerns
The TRP identified several issues that it said should be addressed in grant-making and grant implementation.
Treatment approaches for key populations. The TRP observed that Burkina Faso did not present data in the funding request on the treatment cascade for each of the key populations identified; and did not address the tailored approaches needed to accelerate achieving the 90-90-90 targets in female sex workers, MSM, transgendered people and prison populations. During grant-making, this issue was partially addressed when the Burkina Faso CCM prepared a plan with tailored and differentiated strategies (a) to increase access of each key population to interventions on the treatment cascade; and (b) to improve treatment outcomes. The TRP requested that during grant implementation Burkina Faso align its comprehensive package and differentiated approaches for key populations to the current normative guidance; and conduct treatment cascade analysis for key populations.
Human rights and gender. The TRP said that although Burkina Faso addressed, in a general way, some barriers related to human rights and gender, the funding request contained no interventions specific to the issues identified in the request, such as high levels of sexual violence experienced by sex workers and MSM, and discrimination in medical settings against these two key populations. Also, the TRP noted that Burkina Faso identified gold miners and transgendered people as groups affected by HIV, but proposed no specific interventions for these populations. The TRP requested that Burkina Faso:
prioritize programming to address sexual violence against MSM and sex workers;
intensify efforts to address stigma and discrimination in medical settings through sensitization training for medical professionals;
assess specific human rights and gender barriers for transgendered individuals and develop programming that addresses these barriers; and
assess specific human rights-related barriers for gold miners and develop programming that addresses these barriers.
During grant-making, the CCM provided a detailed work plan addressing the issues of stigma and discrimination against MSM, sex workers and transgendered people, including in health services. The work plan covered all areas raised by the TRP with the exception of gold miners. No information is currently available to design specific interventions for that population, the CCM said. It added that it will continue with ad-hoc activities focusing on this population, based on available mapping of known sites; and that a bio-behavioral study is planned which will feed into the design of evidence-based interventions which will be implemented on a larger scale.
Community-based interventions. The TRP identified two issues that it said could hinder program implementation: the motivation of community-based health workers (CHWs), and the quality of services they provide. Weaknesses of the community-based interventions are impeding the success of the integrated management of diseases at community levels, as well as the success of activities related to the prevention of mother-to-child transmission (PMTCT), the TRP said. Management of community-based interventions is being transferred to a civil society SR, and there is an evaluation of community-based organizations planned for 2017, the TRP noted. Finally, the TRP observed that under the funding request, the RSSH budget is being reduced by 20% and that this reduction may affect investments such as expansion of integrated community case management, and the capacity building and motivation of CHWs.
The GAC said that during grant-making, the country team, the PRs and country partners developed innovative interventions designed to maximize the investment in CHWs and community-based organizations (CBOs). These included the involvement of CHWs in TB case detection.
TRP comments on TB
The TRP observed that the TB grant will continue to focus on (a) improving case detection and treatment success rates; (b) improving identification of drug-resistant cases; and (c) ensuring their treatment using the short course multiple-drug-resistant (MDR) regimen the country has adopted.
Issues and concerns
The TRP identified several issues to be dealt with during grant-making and grant implementation. These have been summarized in the six tables below.
Table 2: Case notification
Issue: There was a large gap in the funding request between the estimated incidence of TB and the case notification rate in 2015. Under-notification is particularly high for children under 15, and even higher for children under five. The proportion of children among notified TB cases currently is 3.4% versus the 5-15% range recommended by the World Health Organization. The TRP requested that the CCM develop an action plan to improve case finding among vulnerable populations with a focus on (a) regional peculiarities; (b) intensification of case finding among children, women, elderly people, people living with HIV/AIDS, prisoners and other at-risk groups; (c) intensification of community-based activities; (d) people in certain high-risk occupations, such as gold miners; and (e) the transportation of sputum.
Grant-making: With support from the WHO, Burkina Faso prepared an action plan with appropriate activities, budgets and timelines to improve case finding and other community-based interventions amongst vulnerable populations, with a focus on the groups listed by the TRP. The actions have been included in the new grant.
Table 3: TB in children
Issue: A recent TB program review noted the absence of guidelines for children under 15 and the need to improve access to TB prevention and treatment services. However, there is no mention in the funding request of contact tracing as a method of detecting childhood TB, nor is there any mention of plans to introduce the new pediatric formulation.
Grant-making: During grant making, activities to strengthen case detection and management of TB in children were added to the program. In addition, an order was placed for new pediatric anti-TB medicine formulations. Further, it was revealed that the issue of case detection and management of pediatric TB has been included in the new TB strategic plan as one of the main areas of strategic focus. The WHO, the Global Drug Facility and the TB Supranational Laboratory of Milan have been offering their technical support to the national TB program on this issue, including for the development of TB pediatric guidelines which will be implemented from the first quarter of 2018.
Table 4: Gender gap
Issue: There is a gender gap in accessing services between men and women. The male-to-female ratio for case notification is 6:1, while the ratio of estimated incidence has a ratio of 6:4, implying that a significant number of women are not diagnosed and treated. The TRP requested that the Burkina Faso CCM provide an action plan to assess the underlying reasons for this gender gap, and to address the gap. The TRP also asked the CCM to disaggregate all case finding and outcome data by age and gender in order to monitor progress.
Grant-making: During grant-making, the CCM added some interventions to the grant to address the gender barrier. More interventions will be developed during grant implementation after a gender access study is conducted. It was revealed that the performance framework for the TB grant includes the disaggregation of TB data into gender and age; and that the revised data collection tools recently introduced at national, sub-national and decentralized levels take into consideration this disaggregation.
Table 5: Prisoners
Issue: The incidence of TB among prisoners is 304 per 100,000 population, which is about six times the national TB incidence. Prison conditions are not conducive to proper treatment, and there have been reports of breaches of confidentiality and violence against prisoners whose infection status is known. The TRP noted that these issues were identified previously but that little action was taken.
Grant-making: This was a major focus during grant-making. The GAC said the country team ensured that appropriate interventions were planned in the new grant to adequately address the issue. In addition, Burkina Faso prepared an actionable plan with appropriate activities, budget and timeline to improve case finding and other community-based interventions amongst vulnerable populations with a focus on the groups listed by the TRP. It was pointed out that the new TB national strategic plan largely focused on interventions to improve access to vulnerable populations, including prisoners.
Table 6: Use of GeneXpert machines
Issue: There has been considerable delay in deploying the GeneXpert machines, and the new roll-out plan developed by the Programme National Tuberculose has not gained momentum. Delays in initiating the use of these machines have been due to the fact that inadequate attention has been paid to enabling health systems to make effective use of the machines. There have been problems with maintenance of the machines and with training on the use of the machines. There are related challenges with logistics management of TB laboratory commodities, and there is a need for an overall plan for the TB lab network, especially with respect to sample transport and the supply chain for reagents. The TRP recommended that the CCM include an indicator in the performance framework regarding the cost-per-test performed with the devices, and that Burkina Faso monitor and report against this indicator.
Grant-making: The WHO and the TB Supra National Laboratory of Milan have been providing technical support to develop a GeneXpert introduction and expansion plan that includes all the areas outlined by the TRP. The plan was finalized in September 2017; implementation started during the last quarter of the year and will continue during the implementation of the new grant. Concerning the indicator of cost-per-test performed of the devices, it was revealed that there is no standard indicator that could be included in the performance framework to measure cost per test, and no system in place in the country for such measurement - pending a corporate decision on value for money of the GeneXpert machines. There are ongoing discussions with the Technical Assistance and Partnership Department at the Secretariat on how to address this issue.
Editor's note: It almost sounded to us at Aidspan like the use of the GeneXpert machines was being questioned, whereas we thought they were in pretty widespread use. So, we asked the Secretariat about this. Ibon Villelabeitia of the Communications Department explained it this way:
"The Global Fund supports many countries to introduce and scale up the use of GeneXpert. The main challenge in many countries is optimisation of available GeneXpert machines, including placement and maintenance. Currently, the Global Fund does not have any indicator to monitor the use of GeneXpert machines in our standard M&E indicators. We have been exploring working with partners such as WHO, USAID and others to assess utilisation of GeneXpert machines, including conducting value for money studies."
The GAC reported that government commitments for health sector expenditure for 2018-2020 is about € 240 million higher than the budget allocation for 2015-2017. For the malaria program, the government has committed € 45.5 million to support procurement of artemisinin combination therapies and free health care for pregnant women and children under five. Commitments provided by the government for the TB program for the 2017-2019 allocation period amount to € 381,000 to fund 40.0% of the first line TB drugs and all the ancillary medicines. Government commitments for the HIV program are € 49.5 million, which supports procurement of drugs and other commodities.
The GAC acknowledged Burkina Faso's recent efforts to moves towards increased sustainable health financing and noted its increased contribution to malaria program (by 20.0%) and its introduction of a free health care policy for pregnant women and children under five, which, the GAC said, led to an increase in the number of malaria cases treated, as well as a significant increase in the demand for commodities.
The GAC observed that external funding constitutes 83.2% of Burkina Faso's malaria programming. However, the GAC said there has been a significant increase in the portion of the government's budget devoted to health (now at 12.35%), of which 16.8% goes to malaria. The GAC said this trend is anticipated to continue until the end of 2020.
Some of the information for this article was taken from GF/B38/ER02 (Electronic Report to the Board: Report of the Secretariat's Grant Approvals Committee) and other documents related to the approval of Burkina Faso's grants. These documents are not available on the Global Fund's website.