In October 2016, the Global Fund Board has approved $56.6 million for six grants emanating from concept notes submitted by four countries. Of the $56.6 million, $37.2 million represented new money; the balance was existing funding that has been approved prior to the new funding model (NFM) but was nevertheless included in the NFM allocations to countries. and one regional grant. The Board was acting on recommendations from the Grant Approvals Committee (GAC) and the Technical Review Panel (TRP). The Board awarded $3.9 million in incentive funding and added initiatives worth $2.9 million to the registry of unfunded quality demand. See the table for details.

Table: Funding for country grants approved by the Global Fund, August 2016 ($ million)

Country (component)	Grant name	Principal recipient	Approved funding
			Existing	New	Total
Angola (TB/RSSH)	AGO-T-MOH	Ministry of Health	6.6 m	13.5 m	20.1 m1
Ecuador (HIV)	ECU-H-KIMI	Corporación Kimirina	2.3 m	3.4 m	5.7 m
	ECU-H-MCDS	MCDS	1.6 m	0.0 m	1.6 m
Guineau-Bissau (HIV)	GNB-H-SNLS	SNLS	8.9 m	5.3 m	14.2 m
Kenya (malaria) 2	KEN-M-AMREF	AMREF	0.0 m	2.8 m	2.8 m
	KEN-M-TNT	National Treasury	0.0 m	12.2 m	12.2 m
TOTALS			19.4 m	37.2 m	56.6 m

The balance of this article provides a summary of the comments of the GAC on the funding awards. Angola (TB/RSSH) The TB burden in Angola is high, with an incidence rate of 370 per 100,000 and a prevalence rate of 490 per 100,000 in 2014. The trend in case notifications for all forms of TB shows a progressive increase from 2007 to 2013 but TB case detection rates remain low. The objectives of the Global Fund-financed programs in Angola are:

• to support the expansion of case notifications for all forms of TB to 72,685 cases in 2017 and 77,774 in 2018;
• to provide treatment and diagnostic equipment needs for multidrug resistant TB in coordination with the Government of Angola;
• to strengthen the epidemiological routine surveillance system, the health information system and program monitoring and evaluation;
• to strengthen the national procurement, storage and supply chain systems;
• to increase the treatment success rate of bacteriologically confirmed TB cases from 66.2% in 2014 to 85% in 2018;
• to decrease the percentage cases with drug-resistant TB started on treatment for multidrug resistant TB that were lost to follow up after six months, from 12.8% in 2014 to 4% in 2018; and
• to increase the proportion of health management information systems or other routine reporting units submitting timely reports according to national guidelines from 45.1% in 2015 to 100% in 2018.

In its report, the GAC Secretariat identified several major risks for the Angola programs and have put in place the following mitigation measures to counter weak program management capacity and poor absorption and Risk of treatment disruptions due to a weakness in the national storage system and supply chain. For the former, a technical support unit is being established to provide technical assistance, build capacity and drive implementation of the new grants implemented by the Ministry of Health, to replace the existing program management unit with the help of a transition team. For the latter, Global Fund-financed commodities will be distributed using a private sector service provider who also stores and distributes Global Fund-financed HIV health commodities, in order to assure their delivery to end users at beneficiary facilities. Furthermore, it was found that poor TB data quality was an issue and what was needed was for long-term technical assistance to be provided to the national TB program throughout the duration of the grant, particularly for community-based DOTS, diagnostics strengthening, MDR-TB, and TB/HIV integrated services. The grant budget includes funds to train TB focal point officers at provincial level in all 18 provinces monitoring on evaluation and statistical analysis. The report stated that this would be periodically reinforced by routine supervision to ensure strengthening of capacity, and improve decision-making processes. It was noted by the GAC that the Angolan TB program does not presently have a reporting system at the community level and the integration of community-level data collected by community health workers is still under discussion. To rectify this, the Ministry of Health will integrate community-based DOTs indicators into the new national TB monitoring and evaluation framework and the national TB program will validate the reporting tools at all levels. Of particular interest, is that the report makes mention of an investigation conducted by the Office of the Investigator General (OIG), in which it identified US$4 million of ineligible expenditures by the Ministry of Health in 2013 under the malaria program as recoverable through procurement fraud. To date, US$2.8 million has been recovered and in order to prevent such fraud occurring in the future, new measures for the use of program funds are being enforced including engaging a fiscal agent financed by the Ministry of Health, and provisioning for a fiscal agent to oversee the financial management and procurement of non-health goods and services. In the meantime, Angolan authorities have arrested and indicted the officials involved and criminal proceedings are ongoing. The repayment of the outstanding US$1.2 million has been included as a condition in the new malaria grant and the Secretariat will continue to engage the Government of Angola on this subject. Total domestic financial commitments from Angola for TB amount to 14.4 million, which represents 59 % of total resources available for the next implementation period. The 2016 budget reflects a 24% increase for health. TB-specific budget lines have been created to track expenditures . The government has provided a written commitment to procure all first-line TB drugs and their share of other TB health commodities as well as absorbing the costs associated with second-line TB drugs by December 2018. The report states that all procurements will be closely monitored by the Secretariat. The GAC had numerous recommendations as a result of its findings. In short, the GAC called on partners to invest in high-level dialogue to ensure sustained increase and delivery of domestic financial commitments for health, with specific reference to the TB program and building resilient and sustainable systems for health, and highlighted the need for partners’ collaboration to ensure long-term technical support to the country. Ecuador Ecuador’s HIV epidemic is concentrated in men who have sex with men and transgender women, with respective prevalence rates of 11 % and a 31.9 % in urban areas. The goal of the Global Fund-supported program is to contribute to achieving the 90-90-90 goals by intensifying HIV prevention and reducing access barriers to services for key populations in Ecuador. The proposed program includes goals such as an increased %age of men who have sex with men who can obtain a defined package of HIV prevention services, up to 95 % in 2019 in the 8 priority regions through the interventions managed by the civil society principal recipient and increasing the %age of transgender people who are reached with a defined package of HIV prevention services up to 92 % in 2019 in the 8 priority regions through the interventions managed by the civil society principal recipient. Guinea-Bissau The Global Fund-supported program’s goal is to help the country start its transition towards a prosperous, mutually supportive society that guarantees universal access to HIV prevention and AIDS treatment services. Context-specific strategies and activities to support this goal include ensuring essential prevention services for key populations at higher risk of HIV exposure and infection; providing a continuity of essential services for adults and children living with HIV according to their specific needs; and providing complete and reliable strategic information on epidemic trends for decision-making and resource allocation. With regard to the objectives of the proposed programming, the report stated the program intends to “increase the percentage of adults and children with HIV known to be on treatment 12 months after initiation of ART from 73.6 in 2014 to 81 % in 2017, increase the percentage of men who have sex with men who are reached with a defined package of HIV prevention services from 35.7 % in 2015 to 78 % in 2017; and increase the proportion of expected facility reports received during the reporting period to 100 % by 2017.” The report stated that the Global Fund finances 100 % of all human resource costs of the principal recipient, the National AIDS Secretariat. “In order to pursue the objective of increased country ownership and sustainability,” the GAC said, “a condition has been included in the grant agreement that a human resources and sustainability plan level must be submitted by December 2016, with the minimum contribution from the government to cover the salary of the executive secretary of the National AIDS Secretariat by December 2017.” According to the GAC, prior to the signature of the grants in the 2014 to 2016 allocation period, performance incentives for a selected number of staff at sub-recipient and implementation level had been misaligned across the active Global Fund grants in Guinea-Bissau. In order to harmonize top-up levels across the grants, with an eventual aim to phase them out, the CCM submitted a proposal for standardized top-ups to be applied to all grants . The GAC said that the Global Fund has approved this plan and it will be in effect through December 2017, after which point incentives will no longer be paid. The GAC pointed out that the new incentive scheme being implemented is performance-based. The TRP initially reviewed the Guinea-Bissau HIV grant in Window 8 in November 2015 and found that it was not fully strategically focused and lacked a comprehensive analysis of the HIV epidemic. However, due to the challenging operating environment in Guinea Bissau and weak health system capacities, the TRP applied flexibilities and a differentiated approach to managing the Guinea Bissau concept note and decided to recommend it proceed to grant-making rather than go back to the CCM to be re-submitted. The TRP requested the applicant to revisit the strategic priorities to focus on key priority and high impact interventions including key populations in line with the HIV epidemic and country context and to develop a plan to conduct a biological and behavioral study among key populations and validate size estimates of key populations and hot spot or geographical mapping of the epidemic to help inform future targeting of the national response and lastly, to develop a time-bound plan with associated budget to strengthen the procurement and supply chain management system, to be implemented during grant implementation. Kenya Grants for the Kenya malaria program were authorized to have a shortened grant duration until 30 June 2017 for KEN-M-AMREF and KEN-M-TNT. In order to continue implementation through 31 December 2017, and to sustain the scope and scale of essential malaria services in 2017, the GAC has recommended the extension of Kenya’s malaria shortened grants. In its review of the Kenya malaria program, the TRP, GAC and Board raised several concerns that were addressed by the applicant. The Principal Recipient developed a risk mitigation plan to address the challenges arising from devolution, including guidelines to enhance accountability and efficient use of resources at the national- and county-level. The implementation of this plan is currently underway. To address concerns over incentive payments to community health workers, the community health strategy department of the Ministry of Health will lead the process of developing a sustainability plan in which the malaria program and counties will participate. The Ministry of Health, together with key stakeholders, will work towards ensuring that counties take over. To this end, the county of Siaya has already taken over these payments and the Secretariat anticipates that the other counties will gradually take over this function as well. Additionally, a US$500,000 special initiative through the Bill and Melinda Gates Foundation will finance advocacy workshops and sensitization activities with parliamentarians, county executives and active engagement of the Secretariat, to encourage increased domestic financing and putting more funding into the county and national health budgets. The Kenyan government has contributed counterpart financing and wiliness-to-pay over the last two consecutive financial years of 2015 to 2016 and 2016 to 2017 has been US$26 million and US$28 million, respectively, out of which approximately US$6 million was committed to fund the malaria component for procurement of health commodities. The government seems committed to increasing the share of health in total government expenditure and is in the process of implementing a number of initiatives to improve domestic financing and address financing gaps for health programs. The other disease components with Shortened Grant implementation periods  for which funding has not yet been approved by the Board are Kenya malaria, Mozambique Malaria, Mozambique HIV, Sudan Malaria, Tanzania HIV, Uganda Malaria, Uganda HIV, Zimbabwe Malaria, Congo (Democratic Republic) Malaria, Nigeria Malaria, and Ghana Malaria. Information for this article comes from the report of the Secretariat’s Grant Approvals Committee to the Board (GF-B35-ER12). This document is not available on the Fund’s website.