Roll-Back Malaria Board Meeting 10 November 2008 Professor Rifat Atun Malaria Round 8 Lessons Learned & Outcomes of 18th Global Fund Board Meeting Roll-Back Malaria Board Meeting 10 November 2008 Professor Rifat Atun Director, Strategy, Policy and Performance Cluster The Global Fund

Global Fund is committed to impact on malaria Dedicated to targets of GMAP Working with partner on prevention, scaling up effective treatment & on TA in areas such as procurement Providing flexible financing while adhering to PBF for impact Round 8 represents a significant step in increasing value of funds – GF is integral to the fight against malaria GMAP= Global Malaria Action Plan PBF= Performance Based Funding

Results: people reached with services Indicator Mid 2007 Mid 2008 % increase since mid 2007 HIV: People on ART 1.1 million 1.75 million 59% TB: DOTS treatment 2.8 million 3.9 million 39% Malaria: ITNs distributed 30 million 59 million 97%

Acceleration of scale up

Increasing country evidence of malaria impact Declining malaria in health facilities after intervention: Rwanda, 2001-2007 Other evidence of impact on malaria: Pilot trials of ITNs in Kenya showed child mortality improvement and economic benefits. Southern Africa showed the benefits of integrating spraying and effective treatment. National declines: Global Fund-supported programs now show similar evidence of national declines in malaria and child mortality in Burundi, Eritrea, Swaziland, Kenya, Mozambique and Zanzibar, with initial signs of decline in Ethiopia and Zambia. Incidence↓~64% 2001 2002 2003 2005 2007 2006 2004 Year

Malaria Grants – Rounds 1 to 7 West Pacific Andean Situation in current grants. Total lifetime budget is US$ 3.2 bn Linking money to results - ITNs distributed: Mid 2007: 30 million Mid 2008: 59 million (% of target met: ITN - 118% ) % increase since mid 2007: 97% Note for Bill: During the PC you were asked: Do we have indicators on net use?  If so, what is it? And if no, what are the constraints with respect to collecting such data? Answer: Many, but not all, grants have outcome indicators on net use within the performance framework. This data are obtained through surveys (most commonly DHS [Demographic health Survey] or MICS [Multiple Indicator Cluster Survey]) which are usually conducted every two or three years, and often it takes nearly a year to make the results available. For those without outcome indicators there is a need for capacity to conduct surveys and budget it appropriately. Consequently, many grants were yet to report on results, until the World Malaria Report, 2008, was launched in September – it provides such data by country and survey. RMCC Total lifetime budget (million USD) Less than 20 20-50 More than 50

Performance rating at 18 months On average TB grants are performing better that HIV and malaria grants at Phase 2 evaluation, that is almost two year from the beginning of implementation. This slide illustrates that TB grants perform better than Malaria and HIV grants in phase 2 evaluation: 33% of TB grants received A rating compared to 23% of HIV/AIDS grants and 13% of malaria grants Possible reasons: maturity and strength of TB programs, efficient international technical assistance provided by Who and STB Partnership, including international procurement mechanisms * Includes HIV/TB grants 7

Round 8: TRP Recommendations Number recommended for funding Within disease success rate 2 Year Upper Ceiling all Recommended (US$ millions) Percent of 2 Year Upper Ceiling Budget 5 Year Upper Percent of 5 Year Upper Ceiling 37 of 76 49% 1,196 38% 3,416 46% 29 of 57 51% 344 11% 960 13% 28 of 41 68% 1,623 3,014 41% 94 of 174 54% 3,163 100% 7,390 Disease Proposal HIV (including HSS requests) Tuberculosis (including HSS requests) Malaria (including HSS requests) TOTAL

Round 8: TRP Recommendations

Category 2B Proposals: Composite Index 3 No. Country Disease 88 Bulgaria Tuberculosis 89 Bolivia Malaria 90 Fiji Tuberculosis, incl CCHSS 91 Guyana 92 Kazakhstan 93 Sri Lanka 94 Tunisia

Round 8: Key Outcomes - Number of Proposals Overall success rate: 54% (94 of 174, highest to date) Within the Diseases: Malaria: 68% Tuberculosis: 51% HIV: 49% Health systems strengthening 'parts' fared well Overall success rate: 56% (25 of 45, as part of 174)

Board Decision Point GF/B18/DP7 on AMFm Policy Framework and Implementation Plan approved GFATM to host and manage the AMFm in Phase 1 in a limited number of countries Pre launch overseen by AMFm Ad Hoc Committee 19th Board meeting: decision on the Governance structure for the oversight and performance monitoring of implementation of Phase 1 Independent technical evaluation of AMFm roll-out Work and support of the RBM Task Force, UNITAID and other partners acknowledged and their support requested to develop and implementation of AMFm

Funding Decision Round 8 Phase 1: proposals to be approved for funding—collectively subject to a 10% efficiency adjustment: max. limit of $2.753Bn for P1 Category 1’ and ‘Category 2’ with composite indices 8, 6, and 5 Round 8 Phase 2: Collectively be subject to a maximum limit of $3.087Bn* (75% of the P2 amounts in the R8 recommended proposals). New Rolling Continuation Channel (RCC): RCC 1 approved by the Board each be subject to a limit of 140% of the amount of the incremental funding approved for the P2 period of the relevant expiring grant. Phase 2 and RCC: Efficiency savings of 10% (US$0.5Bn) until 31 December 2010, in P2 renewals of existing grants and upcoming RCC renewals Round 9: deadline for submission of proposals extended to 6/2009. *Limit may be partially or fully relaxed If new resources become available

Decision: Approval of Round 8 The Board approves for funding for an initial two years those Round 8 proposals recommended for funding by the Technical Review Panel (TRP) as ‘Category 1’ and ‘Category 2’ with composite indices 8, 6, and 5

Category 1 No. Country Disease 1 Afghanistan Tuberculosis 2 Armenia 3 Belarus HIV, incl. CCHSS 4 Gabon HIV 5 Mauritius 6 Moldova 7 West Bank and Gaza 8 Peru 9 Ethiopia Malaria, incl. CCHSS 10 Indonesia 11 12 Mauritania HIV, CCHSS only 13 Sao Tome and Principe 14 Swaziland Malaria 15 Thailand 16 Zambia

Category 2: Proposals with Composite Index 8 No. Country Disease 17 Burkina Faso Malaria 18 Central African Republic 19 Chad HIV 20 Côte d'Ivoire 21 Mali HIV, disease part only 22 Tajikistan 23 Togo 24 Bangladesh TB, incl. CCHSS 25 Democratic Republic of Congo 26 27 Eritrea 28 Ghana 29 Malaria, disease part only 30 Lao People's Democratic Republic HIV, incl. CCHSS 31 Liberia 32 Mozambique HIV, CCHSS only 33 Nigeria 34 Pakistan Tuberculosis 35 United Republic of Tanzania 36 Vietnam 37 Zimbabwe

Category 2: Proposals with Composite Index 6 No. Country Disease 38 Armenia HIV, CCHSS only 39 China HIV 40 Paraguay HIV, disease part only 41 Guyana 42 Lesotho HIV, incl. CCHSS 43 Swaziland 44 Tuberculosis 45 Thailand

Category 2: Proposals with Composite Index 5 No. Country Disease 46 Comoros Malaria, disease part only 47 Democratic People's Republic of Korea Malaria 48 Gambia HIV, incl. CCHSS 49 Guinea-Bissau Tuberculosis, CCHSS only 50 Tajikistan 51 Tuberculosis, incl. CCHSS 52 Zanzibar Malaria, incl. CCHSS 53 Kyrgyz Republic 54 Madagascar HIV 55 Papua New Guinea 56 Rwanda 57 Somalia 58 United Republic of Tanzania 59 Zimbabwe

Category 2 Composite Index 3 and Category 2B Round 8 proposals recommended for funding by the TRP and identified as ‘Category 2’ proposals with composite index 3 and ‘Category 2B’ will be approved for funding for an initial two years (subject to): through Board confirmation by email (or, if appropriate, at the 19th Board Meeting), as funds become available under the terms of the Comprehensive Funding Policy; and based on the composite ranking of such proposals in compliance with Board’s decision entitled ‘Prioritization in Resource Constrained Environments’

Category 2: Proposals with Composite Index 3 No. Country Disease 60 Brazil Malaria 61 Colombia 62 Serbia HIV 63 Cape Verde 64 Dominican Republic 65 Ecuador 66 Indonesia 67 Nicaragua

Category 2B Proposals: Composite Index 8 No. Country Disease 68 Burkina Faso Tuberculosis, incl. CCHSS 69 Chad Tuberculosis 70 Burundi HIV 71 Nigeria Malaria 72 Sudan, Northern Sector Tuberculosis, incl CCHSS 73 Zimbabwe

Category 2B Proposals: Composite Index 6 No. Country Disease 74 China Tuberculosis 75 Congo (Republic of) Malaria 76 77 Moldova HIV 78 Iran 79 Lesotho

Category 2B Proposals: Composite Index 5 No. Country Disease 80 Afghanistan Malaria, incl CCHSS 81 Democratic People's Republic of Korea Tuberculosis 82 Haiti Malaria 83 Madagascar 84 Solomon Islands HIV CCHSS only 85 86 Uzbekistan 87

Malaria Grants – Round 8 Total 5-year ceiling amount (million USD) [Round 8 map including the 2B] Situation in Round 8 Total 5.year ceiling amount for recommended grants (including 2b) is US$ 2.9 bn – for Round 7 the amount was about US$ $1bn [Note: Phase 1 amount in R8 was US$1,6bn (about half of recommended Upper Ceiling request); Phase 1 amount in R7 was US$ 469 million (42% of recommended Upper Ceiling request)] Round 8 represents a significant step towards increasing value for money. Total 5-year ceiling amount (million USD) Less than 20 20-50 HSS component More than 50

Malaria Grants – Round 8 Total 5-year ceiling amount (million USD) [Round 8 map without the 2B] Situation in Round 8 Total 5.year ceiling amount for recommended grants (excluding 2b) is US$ 2.1 bn – for Round 7 the amount was about US$1bn [Note: Phase 1 amount in R8 was US$1,1 bn (about half of recommended Upper Ceiling request); Phase 1 amount in R7 was US$ 469 million (42% of recommended Upper Ceiling request)] Round 8 represents a significant step towards increasing value for money. Total 5-year ceiling amount (million USD) Less than 20 20-50 HSS component More than 50

Malaria – proposal support working well This slide displays the success rate of proposals. Malaria is the component that is by far the most successful now.

Round 8 – specific malaria outcomes 80% 1800 1600 70% 1400 60% 1200 50% 5 6 7 8 5 1000 6 40% Proposal success rate 7 800 Total 2-year ceiling amount (million USD) 8 30% 600 20% 400 These charts illustrate the high success rate for round 8 compared to other rounds as well as the MUCH larger total amount approved for Round 8. First time malaria has exceeded HIV upper ceiling (R8,US$ 1.2b) AFRO outcomes especially: Equals 50% of all malaria proposals recommended. Internal AFRO success rate of 78% (14 of 18). 78% of these 14 (n=11) have not had a malaria proposal approved since Round 5 or earlier. HSS part: internal success of HSS inside Malaria: 50%. 4 parts recommended: Ethiopia, Zanzibar, Zimbabwe, Afghanistan [Afghanistan is 2b – revise if necessary] 4 parts not recommended: Comoros, Rwanda, Ghana, SADC (multi-country) 10% 200 0% 2-year ceiling amount Success Rate

Topics of discussion (1) Gender Overall, fewer proposals were 'gender transformative' However, more diversity (and strength) when included No proposal 'not recommended' if did not include gender Opportunity for 'case studies' to be released for R9

Topics of discussion (2) Health Systems Strengthening: Cross-cutting HSS requests 'possible' in Rd 8 formulation Yet, WHO Building Blocks not optimal as 'operational framework' on which to prepare integrated responses to constraints, leading to 'formulaic' elaborations of HSS needs (Note: Few requests in Financing; Leadership/Governance) Community Systems Strengthening Most proposals included some level of CSS activity Covered the full range of activities However, not easily 'extracted' for analysis/proof of concept All Round 8 Proposals[1] Received 78% of the 230[2] Round 8 proposals received included CSS activities. Low income applicants included CSS activities more often in their proposals (82%) than either lower-middle (77%) or upper-middle income countries (70%). Proposals from SEARO included CSS activities most often (95%), followed by WPRO, AFRO and EMRO (80-90%), and EURO and AMRO least often (65%). Category 1, 2 or 2B Recommended Proposals 84% of the 108 proposals recommended for funding by the TRP as Category 1, 2 or 2B included CSS activities. Proposals from AFRO, SEARO and WPRO were 10-20% more likely to include CSS activities then proposals from AMRO, EMRO, and EURO. Malaria and HIV proposals included CSS activities 15-25% more often than Tuberculosis or section 4B HSS cross-cutting proposals. [1] For the purposes of this analysis, section 4B health systems strengthening cross-cutting interventions were analyzed and included as separate proposals. [2] Not including non-CCM proposals.

Extract of specific recommendations Delay applying for funding if no track record for performance: Especially when applicants are requesting 'scaling up' of activities from an earlier grant that has not started/not signed, or just beginning Value for money: pre-TRP financial review of 'large budgets' Health workforce salary requests: recommendation for Global Fund to identify principles that guide requests for salary support – with particular focus on National HR plans Eligibility for multi-country proposals: Reduce proposals that 'select' eligible countries rather than focusing on epidemiological/social/political issues TRP Report has a number of 'headline issues' in Part 5 of the main body of the Report. As a snap shot: HIV – positive innovation, including introduction of at least one 'go to scale' male circumcision program. However, too many proposals coming without a recent epidemiological study to base funding request. Tuberculosis – concern over the 'formulaic' use of the StopTB planning tool. People including "the full list" of recommended interventions, and not focusing on their country, their priorities, and their capacity to implement. Malaria – strong entomology and epidemiological basis for proposals. Malaria: AFRO is 50% of all malaria recommended, and 14 of 18 malaria proposals from AFRO supported. Most hadn't been funded since Round 5 or earlier. Existing Global Fund grants & grant consolidation – TRP recommending more of a focus on bringing 'the national approach'. SIE data that enables the TRP to know what 'the Global Fund', and not what each grant brings is preferred. Applicants need to reflect more fully on additionality of future funding requests. HIV/TB co-infection: Role for Partners to emphasize more Infant feeding – requests for broad scale distribution of funding for infant formula. Role for partners to be more robust in explaining when not appropriate. Sub-national proposals – need to require better demonstration of avoiding duplication, and also working with CCM (unless situation renders difficult). Accelerate architecture review

Indexing