On 20 March 2017, Malawi’s country coordinating mechanism (CCM) submitted a joint TB/HIV funding request to the Global Fund for $384.8 million, along with a prioritized above-allocation request (PAAR) of $115.0 million, for a total request of just under a half-billion dollars. The within-allocation portion of the request ($384.8 million) includes $31.5 million for initiatives designed to build resilient and sustainable systems for health (RSSH). The CCM is proposing an implementation period of 1 January 2018 to 31 December 2020 for grants emanating from the request. Malawi also submitted a malaria funding request valued at $65.7 million. This article provides a summary of the TB/HIV funding request, including the RSSH portion. The funding request is heavily tilted towards HIV programming (88% of total request), with 63% of HIV funds allocated for the purchase of antiretrovirals (ARVs). Global Fund grants have traditionally supported nearly all ARV procurement in Malawi.  Thirteen percent of the HIV budget is devoted to prevention and testing initiatives.  TB programs, which account for 3.6% of the request, are mostly focused on care and treatment for people living with TB, and addressing multi-drug-resistant TB cases. The funding request used the “tailored – material change” approach, as suggested by the Global Fund in its December 2016 allocation letter. The tailored approach, rather than the more exhaustive “full review,” was suggested because while Malawi is proposing some material changes to its programs, the changes are in limited and defined program areas. Also, the strategic plans on which the TB and HIV programs are based – i.e. the National HIV and AIDS Strategic Plan; the National Strategic Plan for Tuberculosis Prevention, Care and Control; and the National Prevention Strategy – are all ongoing; there have been no significant revisions to these plans. In its allocation letter for Malawi, the Global Fund provided an indicative disease split as follows: HIV – $370.8 million (82.3%) TB – $9.0 million (1.9%) Malaria – $70.7 million (15.6%) Total – $450.5 million However, the Malawi CCM determined that it wanted to boost the TB component and incorporate some RSSH investments. Thus, the CCM proposed – and the Fund accepted – a different program split, as follows: HIV – $339.3 million (75.3%) TB – $13.9 million (3.1%) Malaria – $65.7 million (14.6%) RSSH – $31.5 million (7.0%) Total – $450.5 million In addition to the core allocation, $10 million was made available to Malawi in the form of “matching funds” – $7 million to support programs for adolescent girls and young women (AGYW) and another $3 million for health data systems. To qualify for these awards, Malawi has to meet certain conditions. A request for these matching funds was included with the funding request. Based on its allocation, Malawi continues to be among the top recipients of Global Fund grants. Despite this fact, some Malawians, including Maziko Matemba, Vice-Chair of the CCM, contend it is far from enough. “These allocations, pivotal as they are, as Malawi relies heavily on Global Fund resources for her HIV, TB, and malaria programs, were far below the needs of the three programs,” said Mr. Matemba. According to figures presented by the Malawi CCM during program split negotiations, the allocations for TB and HIV covered approximately 50% of the projected needs for the next three years. The malaria funding gap is much wider: The Global Fund contribution to malaria will cover only 30% of the estimated program needs for the next three years. Key interventions proposed in the request One of the primary investments of Global Fund grants in Malawi is the procurement of all HIV antiretroviral drugs. According to grant documents, at the start of 2017, Malawi had 679,056 people living with HIV who were on treatment. Treatment initiation has been on an upward trend since the nationwide adoption of “Test and Start” in September 2016, whereby newly diagnosed persons initiate treatment immediately. The funding request includes $214.0 million for ARVs, and additional amounts for treatment and prevention of opportunistic infections ($27.1 million) and viral load testing ($44.6 million). The request also includes $29.8 million for HIV prevention programs and $15.4 million for HIV testing services. An important feature in this funding request is the significant investment in HIV care and prevention for key populations. Malawi proposes to increase the number of men who have sex with men (MSM) who receive a comprehensive package of HIV services from 1,350 in 2017 to 3,600 by 2020. In addition, the country has set a target of 6,000 sex workers receiving a comprehensive service package by 2020. This represents a 300% increase over current programmatic reach in this community. The funding request includes HIV prevention and testing services for MSM and sex workers. Veronica Petro, a sex worker advocate from Chiradzulu, commended the inclusion: “I am happy to be considered in Global Fund programs. There must be an enabling environment for sex work and I need proper tools to do my work safely because I want to have a healthy life.” The funding request includes much-needed HIV services for people in prisons and other closed settings. Whereas Malawi has made significant progress in reducing HIV prevalence among the general population to the current rate of 8.8%, the country continues to face a disproportionately high level of HIV infection among prisoners; Malawi’s two central prisons have HIV prevalence rates of nearly 40%. This is the first time that Malawi is targeting this population. The request calls for $254,000 to be invested in a comprehensive service package for the country’s 23 prisons. Activities include peer educator training and prison health day campaigns. Although it is a comparatively small investment, prisoner advocates see it as a step in the right direction. “I have spent three years in prison and have seen first-hand how an inmate will arrive in prison healthy, only to leave infected with HIV and TB,” said Max Mdoka, founder of Prison Partners for Health Improvement. “Inclusion of an allocation to cater for HIV programs in prisons will help us deal with this serious problem and change many inmates’ lives.” Health systems RSSH interventions account for $31.5 million, or about 8% of the funding request (7% of Malawi’s total allocation), which is lower than the 10.1% the Global Fund cites (in its allocation letter) as the average RSSH investment for countries with similar income levels. RSSH investments are intended to strengthen overall health infrastructure and capacity, rather than produce specific disease-based outcomes. This section of the funding request includes seven modules. See the table for details.

Table: RSSH investments

Note: Discrepancy between this total ($31.3 million) and the amount for RSSH in the budget ($31.5 million) due to rounding.

One key RSSH investment area in the funding request is human resources. There is a persistent human resource management challenge in Malawi, as evidenced by the delayed staffing of 1,200 health care worker (HCW) positions over the course of the current grant, which hindered Malawi’s ability to reach its HIV and TB targets. The funding request, therefore, includes capacity building of the Health Service Commission to address the recruitment challenges. The Commission is responsible for staffing health worker positions. The request also includes supplements to the salary and benefit packages for HCWs to enhance recruitment and retention outcomes. Implementation arrangements The funding request states that the current implementation arrangements will be maintained. There are two principal recipients. The Ministry of Health (MOH) will manage the various biomedical components of the program, which includes quantification, forecasting, storage and distribution of medicines and procurement of non-health products, service delivery at primary, secondary and tertiary facilities and interventions related to health system strengthening. ActionAid International Malawi will be responsible for the non-biomedical interventions, such as community level service delivery and care, engagement and networking of community-based organizations, contribution to case finding at the community level, referrals, support for treatment adherence, and community mobilization and demand creation for services. Developing the request The timeline for Malawi to develop and submit its funding request was exceptionally tight: roughly three months from receipt of the allocation letter to submission of the request by the Window 1 deadline. Meeting this deadline was a priority for the CCM and the fund portfolio manager – and affected communities as well – because it was seen as critical to ensuring there would be no interruptions in drug procurements and other services supported by Global Fund grants. Given the tight timeframes, an extraordinary commitment was required from the CCM and key stakeholders as they engaged in evidence-based negotiations and consensus building processes. Malawian civil society organizations (CSOs), which have been somewhat marginalized during the current grant, strategized and took a proactive approach to the development of the funding request. The CSOs came together and approached the MOH to learn about the implementation challenges and what the MOH thought would be the best role for communities in addressing those challenges. One of the key challenges that the MOH highlighted was national progress on achieving the “third 90,” a reference to the UNAIDS target of 90% of people on HIV antiretroviral therapy achieving viral suppression. Data shows that 24% of Malawians who test positive for HIV and who initiate treatment are not retained in care after twelve months. “Although we believe that the true proportion of people retained on treatment at twelve months is higher than reported, this loss to follow up is still worrying and it calls for adequate treatment literacy and public education on [antiretroviral therapy],” said Dr. Thoko Kalua, Deputy Director of HIV and AIDS at the Ministry of Health. This is an area where community systems can play an important role. As such, CSOs advocated for inclusion in the funding request of community-level interventions such as treatment literacy education and linkages to community-based support. These interventions were ultimately included. However, the overall investment in community systems was hampered by the decision to devote only 7% of the country’s allocation to RSSH, which is the part of the funding request that covers community systems strengthening interventions. Next steps The Technical Review Panel (TRP) recommended that the funding request proceed to grant-making, which the PRs, CCM, and the Global Fund Secretariat are currently engaged in. The Malawi CCM is on track to address the TRP’s clarifications and recommendations by 31 July, with hopes that a disbursement-ready grant can be signed by the end of the year. This article was co-authored by first-time GFO contributor Abigail Dzimadzi. Abigail is Coordinator of the Malawi Network of AIDS Service Organizations, and was closely involved in the development of the funding request.