Stop TB chief warns of unspent Global Fund grants

In December, the Global Fund to Fight AIDS, Tuberculosis and Malaria will notify countries eligible for grant funding for 2017-2019.

The letters will contain information on each country’s allocation and how they can access new funding, which was made possible by the fund’s successful replenishment in September. Donors pledged $12.9 billion to the fund for the next three years — $1 billion more than the fund’s replenishment conference in 2013.

Countries are likely looking forward to receiving the notifications, as it signifies further funding for their HIV and AIDS, malaria and TB programs. Lucica Ditiu, executive director at the Stop TB Partnership, however, has some concerns.

“What happens very often is that when people receive the information about having new funding, they actually completely decrease their attention to their current funding [and] focus on the fact that they will get new money,” she told Devex. “I wanted to make sure that people are aware that we still have 13 months of implementation of the current allocation,” she said of those recipients whose grants end in December 2017.

Ditiu’s concerns stem from emerging information on how Global Fund’s policies will affect upcoming funding allocations and requests for implementation extensions. The Global Fund will no longer allow grants committed during 2014-2016 to be used together with new grants for 2017-2019 allocation period. This approach is part of the Global Fund’s funding model launch in 2014, but it will be implemented for the first time in the upcoming allocation period.

Countries with grants from the 2014-2016 allocations should fully utilize their grant money within their corresponding implementation period, which varies among countries.

Some countries whose implementation period covered dates exceeding December 2017 can still use their allocation. Seventy percent of current Global Fund grants will end in December 2017, but the remaining 30 percent have grant implementation dates into 2018 and beyond, said Ibon Villelabeitia, part of the editorial team of the Global Fund’s communications department.

“The allocation for 2017-2019 will fund three-year grants that are board-approved during this period; these grants need to last until at minimum December 2020,” he added.

But once countries’ implementation period ends, they will no longer be able to use their unspent funds. Instead the Global Fund will pool the unused money and invest it in other grant programs that have shown “high absorption levels and good performance,” Villelabeitia said. In some cases, the money may not necessarily be invested in the same country or on the same disease burden it was originally put toward, according to David Garmaise, editor of the Global Fund Observer and senior analyst at Aidspan, based on his liaisons with the multilateral donor.

The Global Fund maintains its policy for grant extensions, but it’s a rigorous process that takes time and only applies in certain circumstances, such as when countries were unable to submit their concept notes on time because of events out of their control, or the concept note development or grant making process is more complex and therefore requires longer time periods, or when unexpected delays occur in grant signing or disbursement.

When an extension requires additional funding that cannot come from grant savings, or what the Global Fund calls costed extensions, the amount used for the extended period will be deducted from the applicant’s next funding allocation, in this case 2017-2019.

Ditiu is most concerned about the likelihood of unused TB grants being invested in other programs, given the already limited funding available for TB programs worldwide. In the Global Fund’s new allocation period, TB will receive the smallest share among the three diseases at 18 percent of the total resources available for 2017-2019.

The plan

Ditiu’s concerns led her and the team at Stop TB Partnership to set up a helpline for those recipients that may be experiencing challenges or barriers in utilizing the full Global Fund grants.

“Send an email to share with us the bottlenecks you face (irrespective of their nature) in putting the funds to work,” she said in a mass email to all Global Fund grantees early November. “We will do our best to support you [to] overcome them.”

While Global Fund country teams have been communicating to grantees what will likely happen to unused grant funds, Ditiu is of the view some recipients have been taking the information lightly. In response, the Stop TB Partnership came forward with detailed information that points out that no funding will be carried forward from the current allocation to the next. Since the helpline’s launch, the Stop TB Partnership has received several piece of feedback from its network of Global Fund grantees.

Some of the main barriers grantees are reporting to the Stop TB team have to do with communication breakdowns among Global Fund principal recipients and sub-recipients, health challenges in health system strengthening, and complicated in-country rules on hiring and procurement.

Not all principal recipients and sub-recipients are receiving the necessary information on their grant applications in time, leading to delays in grant disbursement and program implementation, according to Ditiu.

ActionAid Malawi is one organization that experienced these delays. The international nongovernmental organization is a principal recipient of a Global Fund grant focused on helping the national government of Malawi in its quest to control the TB and HIV epidemic in the country. The INGO was supposed to receive its first grant disbursement in the fourth quarter of 2015, but this was delayed until May 2016 because of recalculations in Malawi’s total funding allocation, which led ActionAid had to revise its grant documents, said Martha Khonje, executive director of ActionAid Malawi.

“The grant performance report for January to June 2016 hence covers actual expenditure of frankly two weeks from the actual disbursements to subrecipients,” she said, referring to Global Fund’s latest performance rating for ActionAid under its HIV/TB grant in Malawi. ActionAid received a rating of “C” or “unacceptable” performance for the given period.

“It does not take into account the context and the reasons behind the context,” Khonje said. “In this case it may be assumed that ActionAid Malawi has got funds in December 2015 like the other PRs and has failed to implement up to June, which is not the case.”

Human resources presents another potential setback. It can take recipients months to hire for a key post in their TB programs, which causes delays in program implementation.

“I was saying to someone, if countries come and say my bottleneck is around human resources and it takes me five months to hire a project manager, I will say what do we do with this case?” the executive director said. “Because if they have no one to handle work, and it will take them from May to December to hire someone, that’s almost a lost thing, because even if you bring somebody amazing, you cannot deliver results in four months.”

The National TB Control Program in Pakistan struggled with this issue. They advertised for 13 positions, but struggled to find the right person for the jobs, said Nassir Mahmood, the program’s national manager.

The impact

There’s still 13 months for Global Fund recipients to use their grants, or more for those whose implementation dates started late. But Ditiu is concerned there are already around 15 countries that potentially won’t be able to spend a significant amount of Global Fund grants.

Ditiu declined to name these countries, but she said the Stop TB Partnership is paying close attention to some countries with a high burden of TB, such as the Democratic Republic of the Congo, India, Indonesia, Malawi, Nigeria and Pakistan. These countries received bigger grant allocations in proportion to their TB burden. However, these countries also have some of the most challenging operating environments, she said.

If these countries aren’t able to fully use their current grants, there’s a chance they might receive smaller grants in the next allocation period, said Global Fund’s Villelabeitia. But it’s also possible that countries that have fully utilized their grants will receive smaller funding, too, he added.

In allocating funds, the Global Fund is not just looking at countries’ economic capacity or GNI per capita and disease burden. It also takes into account other factors such as external financing and country components’ past funding shares.

“We are considering both actual and projected spend for all grants in the qualitative adjustment process,” Villelabeitia said. “Countries will not be ‘penalized’ if they have not fully utilized their current grant funds, but the information is part of the overall allocation process.”

Ditiu wants Global Fund TB grant recipients to realize the seriousness of these measures and its implications on global TB work. The executive director said the TB community cannot afford to lose any of its funding, given the burden of TB disease worldwide is “much higher than we thought.” There are already a huge number of people — 4.3 million in 2015 — that the TB community is unable to reach and put on treatment. To find them, the TB community will need “extra funding, extra effort and extra work.” she said.

The roll out of tools such as new TB drugs and pediatric medicines for kids meeting the dosage guidelines set by WHO in 2010, as well as a shorter multidrug resistant TB regimen could also suffer from reduced funding.

“Global Fund is roughly 65-70 percent of all money in TB, and then we have domestic, and we have just really, really peanuts from Canada and USAID,” Ditiu said. “Our drama is that in TB, we don’t have any other funding mechanism. We don’t have a PEPFAR. We don’t have a President’s Malaria Initiative. We don’t have other places to go for help.”

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