FUNDING REQUEST APPLICATION FORM

Transcription

1 FUNDING REQUEST APPLICATION FORM Full Review SUMMARY INFORMATION Applicant Zambia Component(s) TB/HIV Principal Recipient(s) Ministry of Health (MoH) Churches Health Association of Zambia (CHAZ) Envisioned grant(s) start date 1 January 2018 Envisioned grant(s) end date 31 December 2020 Allocation funding request $194,386,002 Prioritized above allocation request $112,441,057 IMPORTANT: To complete this funding request, please: - Refer to the accompanying Funding Request Instructions: Full Review; Refer to the Information Note for each component as relevant to the funding request, and other guidance available, found on the Global Fund website. Ensure that all mandatory attachments have been completed and attached. To assist with this, an application checklist is provided in the Annex of the Instructions; Ensure consistency across documentation. Applicants are encouraged to submit a joint funding request for eligible disease components and resilient and sustainable systems for health (RSSH). Joint TB/HIV submissions are compulsory for a selected number of countries with highest rates of co-infection. See the related guidance for more information. This funding request includes the following sections: Section 1: Context related to the funding request Section 2: Program elements proposed for Global Fund support, including rationale Section 3: Planned implementation arrangements and risk mitigation measures Section 4: Funding landscape, co-financing and sustainability Section 5: Prioritized above allocation request 22 May

2 SECTION 1: CONTEXT This section should capture in a concise way relevant information on the country context. Attach and refer to key contextual documentation justifying the choice of interventions proposed. To respond, refer to additional guidance provided in the Instructions. 1.1 Key reference documents on country context List contextual documentation for key areas in the table provided below. If key information for effective programming is not available, specify this in the table ( N/A ) and explain in Section 1.2 how this was dealt with within the context of the request, including plans, if any, to address such gaps. Key area Applicable reference document(s) Relevant section(s) & pages N/A Resilient and Sustainable Systems for Health (RSSH) Health system overview 1. Republic of Zambia - Vision Volume 17 - Public Health Act Zambia 3. Zambia National Health Policy (2013) 4. Zambia Human Development Report Draft Seventh National Development Plan (Health Chapter) Zambia National Health Strategy (Draft) Health system strategy Ministry of Youth and Sport (2015) National Youth Policy 8. Ministry of Youth and Sport (2015) Action Plan for Youth Empowerment and Employment 9. Health Sector Supply Chain Strategy and Implementation Plan ( ) 10. The Revised Medical Stores Limited Strategic Plan National Community Health Worker Strategy in Zambia (2010) 12. Adolescent Health Strategy Operational plan, including budgetary framework Gender (pg ) and health sections (pg. 8889) HIV & gender equality section (pg. 13) HIV section (pg. 3) SRH, HIV & GBV sections (pg ) 13. Ministry of Health National Training Operational Plan 2013 to Zambia Demographic and Health Survey Reviews and/or evaluations Health sections (pg. vi, 2-6, 8, 20-21, 24-27, 32 & 35) 15. Mid-Term Review of the Implementation and Performance of the Revised National Health Strategic Plan ( ) 16. American Institutes for Research (2014). Zambia s Multiple Category Targeting Grant: 24-Month Impact Report. HIV (pg ) & GBV (pg ) sections HIV (ps ), TB ), HMIS (pg ) Health Financing (pg ) HRH (pg ) Section on cash transfers on education (pg ) and HIV risk 22 May

3 behaviour (42-43) 17. CHAI and the Ministry of Community Development, Mother and Child Health (2015) Community Health Assistant Program Process Evaluation Report. 18. Inventory of PSM Partners for Zambia Final Assessment Report: Supply Chain Capacities, Beneficiaries and A Way Forward for Improving Access to Essential Medicines and Medical materials (2015) 20. SCMS/USAID (2014) Technical and Organizational Capacity Assessment report for Medical Stores Ltd. 21. World Bank (2011). The Human Resources for Health Crisis in Zambia 22. Strengthening the Role of Nurses and their Frontline Teams to Provide Quality Care in Rural Zambia Results of a Formative Assessment 23. Zambia CCM (2017) Mid-Term Evaluation of the Global Fund New Funding Model in Zambia 24. Constitution of Zambia (Amendment) Act, No. 2 of Ministry of Gender and Child Development (2014) National Gender Policy 26. Persons with Disabilities Act No. 6 of 2012 Human rights and gender considerations (cross-cutting) 27. National Strategy on Ending Child Marriage in Zambia ( ) 28. Government of Zambia and UNDP (2010) Gender Status Report: A Baseline Review 29. Anti-Gender Based Violence Act Review of the Legal Environment Report on the Expert Panel Meeting in Livingstone (April 2016) 31. Review of the Legal Environment Report on the Expert Panel Meeting in Chipata (June 2016) Disease-specific 32. Zambia Populations Based HIV Impact Assessment (ZAMPHIA) Fact Sheet 2015Epidemiologic 2016 al profile 33. WHO (2016) An Evaluation of TB Surveillance (including and TB Zambia Epidemiological Analysis interventions 34. Zambia Sexual Behavioural Survey 2009 for key and 35. Zambia HIV Prevention Response and Modes of Transmission Analysis (2009) vulnerable 36. The prevalence of Tuberculosis in Zambia: populations, Results from the first national TB survey, as relevant) Zambia TB Profile (WHO 2016) 38. Zambia National HIV and AIDS Strategic Disease Framework ( ) GBV (pg. 6-7), HIV (pg. 9-10) and health (pg ) sections Health sections (pg. 8687) Child marriage and sexuality section (pg. 67) Health, mining and GBV sections (pg. 1216) 22 May

4 strategy (including interventions for key and vulnerable populations, as relevant) Operational plan, including budgetary framework Reviews and/or evaluations Human rights and gender considerations 39. Draft Zambia National Strategic Plan for Tuberculosis Prevention, Care and Control ( ) 40. Consolidated Guidelines for Treatment and Prevention of HIV (2016) 41. Adolescent HIV Guidelines (2016) 42. HIV Testing Services National Guidelines (2016) 43. Viral Load & Early Infant Diagnosis Testing Scale-up Implementation Plan ( ) 44. Implementation Plan For Monitoring HIV Drug Resistance in Zambia (Draft) 45. National Operational Plan For The Scale-Up of Voluntary Medical Male Circumcision in Zambia National TB Strategic Plan ( ) National Operational Plan 47. National Tuberculosis and Leprosy Control Program (2015). TB Manual (Fourth Edition) 48. Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis in Zambia (Second Edition) 49. Ministry of Health (2015) HIV Testing Services Implementation Plan ( ) 50. CHAI (2014) National Facility-Based AntiRetroviral Treatment Costing Study in Zambia 51. World Bank (2016) Estimation of Supply and Demand for HIV Services at District Level in Zambia 52. WHO (2016) End-Term Review of the Zambia National TB and Leprosy Control Strategic Plan 53. Global AIDS Monitoring Report (2015) Zambia 54. MoH (2016). Rapid Performance Assessment for Xpert MTB/RIF in Zambia (April 20 May 5, 2016). 55. National AIDS Spending Assessment (2014) 56. EGPAF (2016) Zambia National AIDS Program Outcome and Impact Evaluation 57. CHAI HIV Testing and Counselling: Opportunities for efficiencies in HIV testing 58. EQUIP (2016) Cost and Outcomes of ART Scale-up in Zambia - Modelled Estimated for Test and Treat and Community-based services delivery Models (Policy Brief) 59. EQUIP (2017) Zambia NASF Cost Estimates 60. Pediatric PITC - Assessments, Analysis and Scale-up Plans for Health Facilities in Zambia (2015) 61. NZP+ (2012) Zambia People Living with HIV Stigma Index 62. Panos Institute Southern Africa (2013) Study Report on HIV Prevention for Sexual Minorities All the key reference documents listed above have been catalogued and numbered and are accessible at the following link: Key Reference Documents on Country Context 22 May

5 1.2 Summary of country context To complement the reference documents listed in Section 1.1 above, provide a summary of the critical elements within the context that informed the development of the funding request. The brief description of the context should cover disease-specific and RSSH components, as appropriate, as well as human rights and gender-related considerations. Introduction and Background Zambia has made significant progress towards halting and reversing the HIV and TB epidemics over the last decade. The number of new HIV infections (all ages) has fallen by 29.4% (from 85,000 in to 60,000 in 2015) and TB incidence has fallen by 40% (from 650/100,000 population in 2003, 23 to 391/100,000 population in 2015)., In order to sustain these gains, Zambia has also demonstrated its commitment towards building resilient and sustainable systems for health (RSSH). By decentralizing and differentiating the delivery of care opening more than 650 new health posts since access to services is now closer to communities in need. Building on these successes, Zambia s national disease-specific and health strategies are aligned to the HIV Fast-Track targets, the End TB Strategy and the Sustainable Development Goals (SDGs). However, there is no room for complacency. HIV prevalence remains stubbornly and disproportionately high among key and vulnerable populations and 40% of TB cases in the country go 56 undiagnosed., Compounding these challenges, limited electricity and internet connectivity negatively 7 impacts the quality of services, especially in rural areas. There is a vital window of opportunity for the country to rapidly scale up prevention, treatment and support services over the implementation period, laying the foundation for ending the diseases as public health threats by 2030 This funding request hinges on three critical opportunities in Zambia s HIV, TB and related health systems responses. It is strategically aligned to the National HIV and AIDS Strategic Framework (Annex 1) and the draft National Strategic Plan for Tuberculosis Prevention, Care and Control (Annex 2), both underpinned by the draft National Health Strategy (Annex 3). From a high-level strategic perspective, the proposed investment will enable Zambia to: 1. Further optimize the country s HIV and TB budgets through allocative and technical efficiency factors. Modelling shows this can be done primarily through scale-up of HIV treatment (supported by innovative testing models), prevention of vertical transmission and the front-loading of investments in voluntary medial male circumcision (VMMC). Integrating service delivery is also cost-saving. Focused investments to enhance TB case finding and interventions to improve health seeking behaviour (particularly among men and urban populations) and improving the index of TB suspicion among health care workers, are required to improve TB impact. 2. Reduce gender- and age-related disparities and close gaps among key and vulnerable populations. This includes increasing targeted investments in populations and locations at heightened risk in order to maximize impact and value-for-money. It also requires the differentiated delivery of a comprehensive package to reach those previously left behind. 3. Create a more sustainable HIV and TB response by engendering flexible and adaptable patient-centred systems for health. This includes matching recent investments in infrastructure expansion with adequate human resources for health (HRH), collecting and using patient-level information to guide real-time decision-making, decentralizing service delivery, and building on existing community-level and primary care platforms for a more integrated health response. Overview of the HIV Epidemic in Zambia Out of a population of 16.2 million, there are an estimated 1.2 million people living with HIV (PLHIV) 8 9 (all ages) in Zambia. This figure is expected to increase to 1.3 million by HIV prevalence among the adult population has steadily decreased over time, from 15.6% in , to 14.3% in 2007, to 13.3% in (Figure 1). More recent data from the ZAMPHIA survey suggests that HIV prevalence has continued to decline, with an overall adult HIV prevalence of 11.3% recorded in Despite this progress, there remain distinct gender- and age-related disparities in HIV burden, with 14.5% prevalence among women compared to 8.6% prevalence among men. This disparity is most pronounced among young people aged 20-24, where HIV prevalence is more than 10 four times higher among women (8.6%) as compared to their male peers (2.1%). 22 May

6 Percent Figure 1: HIV Prevalence among Adults (15-49) in Zambia, Over Time, Disaggregated by Sex Men (15-49) Women (15-49) All (15-49) DHS DHS 2007 DHS ZAMPHIA Along with age and gender variance, HIV is not uniformly distributed across the country. Adult (15-59) HIV prevalence varies dramatically by province, ranging from 5.9% in Muchinga to 16.1% in Lusaka (Figure 2). Similarly, rates of viral suppression vary significantly, from 50% in Northern Province to 67.8% in Eastern Province. Greater impact is possible if resources are channelled to these hotspots. Figure 2: Adult HIV Prevalence (Left) and Viral Load Suppression (Right), By Province (2016) 12 Varying rates of HIV prevalence and viral suppression signal gaps in the response in certain locations. Some of the highest unmet need for antiretroviral therapy (ART) is in Mumbwa, Chipata and Lusaka districts. This necessitates more targeted investments in underserved areas. Overlaying these geospatial data, it is clear that there is both high HIV burden and low viral suppression in Western Province. There is also high burden and high unmet need for ART in Lusaka, Mumbwa and parts of the Copperbelt (Figure 3). These areas must be prioritized for infused investment. Figure 3: Number of PLHIV (15-59) (Left) and Unmet Need for ART 13 (Right), May

7 15 Newly available data adds further depth to Zambia s HIV context. ZAMPHIA was the first survey in Zambia to measure national HIV incidence, paediatric HIV prevalence, and viral load suppression (VLS). The survey revealed that there are 46,000 new HIV among adults (15-59) annually, in line with Spectrum estimates that there are 48,677 new HIV infections all ages. It also further underscored the gendered vulnerabilities of the epidemic which must be addressed. HIV incidence is 3.3 times higher among women (15-49) than among men, indicating that prevention among women (especially young women) must be a priority. Further, viral load suppression among women is 3.8 percentage points higher than among men, suggesting a need to prioritize adherence support to men. Table 1: Key findings from the Zambia Population-Based HIV Impact Assessment (ZAMPHIA) Indicator Incidence (%) years Prevalence (%) years 0-14 years Female 95% CI Male 95% CI Total 95% CI Ninety percent of new HIV infections in Zambia are due to unprotected heterosexual sex. Other drivers of new infections include: multiple and concurrent partnerships, low rates of medical male 17 circumcision (54% in 2015, against a target of 80% ), migration and mobility, vertical transmission 18 (2.8% at six-weeks; 5.8% overall ) and social factors that continue to drive high-risk sexual behaviours. Studies have shown that risk factors for vertical transmission in Zambia include late ANC 19 presentation, home delivery, maternal refusal to initiate treatment and loss to follow-up. Studies from Zambia have also shown social factors such as heavy alcohol use are associated with increased seroconversion risk for both men and women, offsetting the prevention impact of HIV prevention 20 counselling that couples may receive by care providers. HIV sub-epidemics among key and vulnerable populations in Zambia also signal the need for a more targeted response. The National HIV and AIDS Strategic Framework (NASF) defines key populations as PLHIV, adolescent girls and young women, young men, inmates, migrants, people who inject drugs, sex workers, gay men and other men who have sex with men, transgender people, children and pregnant women living with HIV, displaced persons, persons with disabilities and people aged 50 years and older (Annex 1, pg ). 21 HIV prevalence among female sex workers in Zambia is estimated at 56.8% (2015) 5 times that of the general adult population (11.3%). Evidence suggests that high prevalence of sexually transmitted infections (i.e. syphilis and trichomonas) is associated with the elevated levels of HIV prevalence among sex workers, with higher burden recorded in Ndola as compared to Lusaka (Figure 4). Figure 4: STI Prevalence in Female Sex Workers in Zambia, by HIV Status and Location Among all women living with HIV, HPV prevalence rates can reach levels as high as 80% in Zambia. 24 As a result, women living with HIV are at 4 5 times greater risk of developing cervical cancer. Zambia s estimated age-standardized incidence and mortality rates from cervical cancer are at 58.0 and 36.2 per 100,000 women, respectively. This national data supports the need to increase access to early cervical cancer screening and treatment through a comprehensive approach to strengthening the delivery of integrated sexual and reproductive health (SRH) and HIV services. 22 May

8 25 A 2010 study (most recent data) among 641 MSM in Zambia found an HIV prevalence of 33%. In Lusaka Central Prison, HIV prevalence in 2011 was twice that of the national population (27% vs %) and 30% greater than in Lusaka province (27% vs 21%). One cross-sectional study in Zambia showed a higher HIV prevalence among already-incarcerated detainees than among those 27 entering prison, suggesting that there may be evidence for seroconversion in prison settings. As such, prevention among inmates is a key priority. Global evidence indicates that criminalization, stigmatization and marginalization drive both higher rates of infection and lower uptake of services among key populations. For instance, the Zambia PLHIV Stigma Index shows that 68.5% of sex workers report being physically harassed or threatened 28 due to their HIV status, compared to an average of 46.7% among the entire sample. This limits access to services. Further, the NASF cites the UNAIDS Advisory Group on HIV and Sex Work, noting that criminal laws related to sex work can undermine sex workers capacity to demand condom use from clients. Additional factors constraining access to HIV services by key and vulnerable populations include: limited data (i.e. population size estimates, epidemiology), legal barriers, prohibition of condom distribution in primary and secondary schools, gender-based violence, low service coverage for children, and harmful socio-cultural norms. Gender inequality and gender-based violence are critical structural drivers of the HIV epidemic among women (particularly young women) in Zambia. For instance, gender inequality is strongly linked with the limited ability of adolescent girls and young women (AGYW) to negotiate condom use. The percentage of AGYW (15 24) who report the use of a condom at last sexual intercourse with a non29 regular partner in the 12 months is just 40%. For adolescent girls (15-19), this figure is even lower (37%). Gender inequality also fuels high rates of age-disparate sex. In 2014, over 7.2% of nonmarried adolescent girls reported having a sexual partner who was 10 years older than them. This points to the need for socioeconomic interventions to address gender inequalities that drive agedisparate sex. It also points to the need for social and behaviour change communication (SBCC) interventions for AGYW to understand the risks from these types of relationships and to seek regular couples testing and counselling. Gender and age inequality within partnerships can increase intimate partner violence. The proportion of ever-married or partnered women who experienced physical or sexual violence from a male intimate partner in the past 12 months is 29.8% among year olds, % among year olds, and 25.2% among year olds. Further, social and cultural norms which disempower AGYW limit health seeking behaviour, with just 60% of adolescent girls ( ) in Zambia saying that they have the final say in their own health care. In the absence of an effective immunization for HIV, universal ART remains the best hope for HIV epidemic control. The initial ZAMPHIA results reveal that Zambia has achieved towards the global targets (Figure 5). This means that about 67.3% of PLHIV in Zambia know their HIV status, 85.4% of all people diagnosed with HIV are receiving ART, and 89.2% of people receiving ART are virally suppressed - against targets of 90% for all three indicators by Though treatment targets have yet to be achieved, increased treatment access has had considerable impact in recent years, justifying its prominence in this funding request. For example, due to effective treatment scale32 up in Zambia, AIDS-related deaths have fallen by 31%, from 29,000 in 2010 to 20,000 in Figure 5: Zambia s HIV Treatment Cascade ( ), Disaggregated by Sex May

9 Zambia s HIV treatment cascade highlights large gaps in HIV testing, particularly among men and adolescents (10-14), and large gaps in viral load suppression, particularly among young people. Differentiated HTS strategies to reach untested populations are a key focus of this funding request. In addition, given that prevalence of viral load suppression (VLS) among HIV-positive people in Zambia is lowest among young people age (34% among women and 35.7% among men) (see Figure 14), there is urgent need for younger cohorts to receive targeted and tailored adherence support. High rates of HIV in Zambia fuel the TB epidemic. The country is classified among the top 30 TB and TB/HIV high burden countries in the world by the World Health Organization (WHO). Zambia s first National TB Prevalence Survey ( ) found that the risk of TB was five times higher among HIV-positive individuals than it was among HIV-negative individuals, with co-infection rates above 34, %. As a result, approximately 70% of TB deaths occur among HIV positive persons. That said, the proportion of HIV-positive TB patients on ART has increased over the years, reaching 76% 37 (17,914 patients) in Yet, gender disparities for integrated activities prevail. The average time 38 from HIV diagnosis to cotrimoxazole initiation is 3.1 months for men and 3.8 months for women. Overview of the TB Epidemic in Zambia Over the last decade, TB incidence has fallen by 40% (from 650/100,000 population in 2003, to /100,000 population in 2015), in large part due to the increased investment in TB diagnosis and treatment and stronger TB/HIV collaboration such as the scale-up of ART in the general population. Figure 6: Total New and Relapse TB Cases in Zambia Figure 7: TB Notifications in Zambia, Disaggregated by Age ( ) Despite progress, innovative approaches are required to accelerate the control of TB. The country s first National TB Prevalence Survey ( ) found that the prevalence of TB in Zambia is higher than previously estimated. The survey estimates national adult prevalence of smear, culture and bacteriologically confirmed TB to be 319/100,000 ( /100,000); 568/100,000 ( /100,000); and 638/100,000 ( /100,000) population, respectively. The TB prevalence for all forms was estimated to be 455/100,000 population for all age groups. The survey also found that in urban settings, the lowest and middle income brackets had nearly double the TB burden than those in the 44 highest income bracket. This signals the need to target investments to urban poor populations. Further, gender disparities in TB burden flag the need for gender-sensitive programming that addresses health inequalities. The TB prevalence survey found that men had twice the TB burden as women program data confirms this gender disparity ratio (Figure 8). 22 May

10 Figure 8: Total TB Notifications in Zambia in 2015, Disaggregated by Age and Sex 3% (1354 cases) 45 3% (1164 cases) Boys (0-14) Girls (0-14) 34% (14,167) 60% (24,903 cases) Women (15+) Men (15+) In 2015, the WHO estimated that incidence of TB was 391/100,000 population. In the same year the WHO estimated incident TB cases to be 63,000 but the country only notified 36,741 new and relapse TB cases representing a TB notification rate of 237/100,000 population. This means that overall, about 40% of TB cases go undetected, underscoring the need to significantly improve TB case finding, especially at community and health facility level. Limited health seeking behaviour paired with low diagnostic capacity contributes to missing TB cases. In a recent study of nearly 7000 Zambians, while the majority reported a history of chest pain (51.1%), cough (35.9%), or fever (15.4%) for two weeks or more, only 34.9% sought care for their symptoms on average three weeks after symptom 46 onset. Of those who sought care, only 13.9% (326) and 12.1% (283) had chest x-ray and sputum examinations, respectively. Men and urban dwellers were less likely to seek care for their symptoms. The proposed program aims to address these patient delays and health care lapses. For those who are successfully diagnosed and placed on appropriate therapy, Zambia has a high TB treatment success rate (TSR) and cure rate. According to the 2016 Global TB Report, the TSR for new cases and relapses TB cases in the 2014 cohort was 85%, and for the previously treated (excluding relapses) it was 80%. TB mortality in 1990 (excluding HIV+TB) was 85/100, population and in 2015 it was 31/100,000 population. The treatment failure rate was 1%, loss to follow-up was 4% and the transfer out rate was 5%, over the same period. Despite fairly good TSR in drug-susceptible TB, multi-drug resistant TB (MDR-TB) is a growing problem in Zambia. The estimated MDR/rifampicin resistant-tb prevalence among new and 49 previously treated TB patients is 1.1% and 18%, respectively. Following approval by the Green Light Committee in 2009, the National TB and Leprosy Program (NTLP) began implementing the Programmatic Management of Drug-Resistant TB. The NTLP plans to implement a real-time results notification system, as well as establish an MDR-TB treatment centre in each province (as of April 2017, this has been done), followed by the addition of other hospitals as treatment centres. In 2015 WHO estimated that there were 1,500 MDR/RR-TB cases among pulmonary new and previously treated patients but only 196 of these cases were detected and just 99 started on treatment. This clearly shows that more effort is required to detect MDR-TB cases and initiate second line treatment. Reasons for low detection and treatment initiation include restrictive guidelines, communication gaps between the diagnostic and treatment initiating hospitals and gaps in informing patients of their results and tracing them to come to the initiating hospitals. The MDR-TB TSR for the 2013 cohort was just 30%, with centralized treatment centres and high loss to follow-up rates as the main reasons. As with HIV, Zambia s TB burden is unevenly distributed in terms of location and population. Copperbelt and Lusaka Provinces have the highest TB burden of 1,211/100,000 and 932/100,000 population (respectively) and account for 57% of TB notifications and 77% of national TB burden. This highlights the disproportionate TB burden both in terms of number of cases and prevalence - in mining communities (Copperbelt) and high-density urban areas (Lusaka) (Figure 9). Recalling Figure 2, Copperbelt and Lusaka are also provinces with high HIV prevalence (16.1% in Lusaka and 14.2% in the Copperbelt), signalling the need for better integrated TB/HIV programming in these areas in particular. The lowest TB burden is in Eastern, Luapula, Muchinga Provinces, with prevalence of 50 around 200/100,000 population. North, Central, Northwest and Western provinces have prevalence of /100,000 population. The Copperbelt is a mining area, where a confluence of biologic and 51 social conditions drives high rates of silicosis, HIV and TB. 22 May

11 Figure 9: Bacteriologically Confirmed TB Prevalence in Zambia, by Province ( ) 52 Key High Estimate Median Estimate Low Estimate In Zambia, the TB program has identified prisoners, mining communities, the urban poor, children, people living in farm blocks, PLHIV and people with diabetes as key populations for the TB response. 53 In 2016, there were 18,560 inmates in 88 prisons in Zambia, representing a 229% occupancy rate. Extreme overcrowding and poor ventilation in Zambia s prisons are key drivers of TB infection in prisons. In Zambian prisons, the TB prevalence is reported to be 6428/100, times the 54 national prevalence. A recent systematic review found that in middle- and low-income countries, 6.3% of TB in the general population is attributable to within-correctional facility spread, indicating the 55 urgent need to address TB in closed settings. Among mine workers, the weighted average of the incidence rate of pulmonary TB from is /100,000 population. The Copperbelt Province, which holds the most copper mines in the country, had a notification rate of 415/100,000 people in 2013 much higher than the national TB notification rate at the time (388/100,000). The national prevalence survey also showed the Copperbelt Province to have the highest prevalence of bacteriologically confirmed TB, at 1211/100,000 population. The low service coverage for children aged 0-14 years is a challenge in the national TB response. 57 Diagnosis of TB in children from was between 6 8%, which is below the WHO recommended 15%. The major challenge for low TB case notifications (besides the common factors for all case notification) is because TB among children is particularly difficult to suspect and diagnose, especially in children under five. Another is that contact investigation is not routine in health facilities. Training for health workers to better identify childhood TB symptoms is prioritized in this request. The legal frameworks for the protection of human rights is based on laws such as the Employment Act.; the Abuja Declaration on HIV, TB and other opportunistic infections of The national TB strategic plan is designed with rights-based approaches. However, the independent review of the TB program identified that there is still insufficient access to health care for certain groups of the population which could fuel increasing levels of TB. For instance, silicosis and TB in mineworkers are occupational lung diseases, and current legislation requires both pre-employment and periodical or annual screening for all mine employees and ex-miners working in scheduled areas and in the mines by the Occupational Health and Safety Institute. Yet, this is not always done. Secondly, there are still high levels of out of pocket expenditures for health, and there is still lack of effective and progressive financial risk protection mechanisms (e.g. pre-payment schemes) particularly for the poor/vulnerable. Specifically for MDR-TB, the limited social support for nutrition and transport reimbursement is a major barrier to improving treatment success rates. 22 May

12 Overview of Zambia s HIV- and TB-related Systems for Health Impact against HIV and TB cannot be optimized or sustained without strong systems for health. The health care system in Zambia is organized into a three-tier pyramidal system whereby at the bottom of the pyramid is the primary health care followed by secondary and tertiary health care. In addition to these public health facilities there are health facilities run by faith-based organizations, mining health facilities, private for-profit and other non-governmental health facilities. In total, there are close to 2000 health facilities in the country. There are also private pharmacies and dispensaries and 40,000 registered traditional health care providers. Yet, there are currently large geographical inequities in terms of access to health facilities. For people living in Mpika, Mkushi and Luangwa, the average distance to the nearest health facility is up to 35km (Figure 10). By comparison, most residents in Kasama, Nyimba and Katete live less than 10km from a facility. Zambia s (draft) National Health Strategy (Annex 3, p. 208) aims to ensure all people are within 5km of a health facility. Figure 10: Average Distance to Nearest Health Facility in Zambia, by District (2011) 58 While distance to facilities forms a barrier to accessing care, inadequate human resources for health compromises the quality of that care. Indeed, universal health coverage (UHC) cannot be realized without an adequate health workforce. From 2011 to 2016 the proportion of all health workers averaged 13.9 clinicians per 10,000 people in Zambia, which is significantly below the 22.8 recommended by WHO. In rural Zambia - where 60.5% of the Zambian population resides and where 59 the burden and mortality ratios are highest - there are just 12.4 clinicians per 10,000. The current number of health workers is estimated at 42,630 (against a need of 63,057). The shortage cuts across all cadres, but is acutely felt among clinicians, nurses, pharmacy technologists, lab technologists and radiographers. A disaggregation of health workers shows that the distribution is skewed toward urban areas (Figure 19). Public facilities in rural/remote areas have the lowest number of health workers. Table 2: Current Staffing Levels Compared to Estimated Need, Select Cadres (2016) Category Administrator Clinical Officer Doctor Lab Midwife Nurses Nutrition Pharmacy Radiography Approved Sector Estimate 22,353 4,883 3,119 2,110 6,322 18, , Actual Staff (2016) 19,254 1,814 1, ,141 11, , Gap (#) 3,099 3,069 1,605 1,189 3,181 6, Gap (%) 14% 63% 51% 56% 50% 37% 42% 5% 23% 22 May

13 Evidence also shows that Zambia s health facilities are not currently operating at maximum efficiency. A recent analysis of Zambia s health facilities staffing, capital inputs and service provision, found an 61 average efficiency score of 49%. However, it was also estimated that Zambia could increase its HIV treatment patient volume by 117%, which means that Zambia s health system likely has the capacity to reach the national goal of providing universal access to HIV treatment, if further investments are made to realize efficiencies and optimize results. A separate study conducted in more than 300 service delivery sites in Kenya, Rwanda, South Africa and Zambia suggests there also are efficiency 62 gains to be made in HIV testing and vertical transmission. In addition, the country s 11 viral load machines are not being optimized, linked with HRH gaps. Part of improving facilities ability to scale up ART must include addressing problems with the 63 planning, procurement and delivery of essential medicines and health commodities. The national supply system has inadequate infrastructure, with regional stores relying on rented facilities that are not designed as pharmaceutical stores. There is inadequate connection between warehouse 64 inventory management and procurement planning. Evaluating the supply chain is also difficult since 65 there are no routine audits. This is exacerbated by shortage of supplies, both in facilities and for use among community health workers. Strengthening the procurement and supply chain management 66 system (PSM) is needed to decentralize services delivery and scale up community-based treatment. The national TB laboratory network includes 370 microscopy laboratories. The country has three laboratories with capacity to detect first line anti-tb drug resistance TB strains through conventional culture and drug susceptibility testing (DST), and modern rapid molecular tests with 69 Xpert MTB/Rif and 2 Line Probe Assay (LPA). But, the distribution of these facilities is not equitable and hence access for microscopy services is sub-optimal. The National TB Reference Laboratory and the Chest Diseases Laboratory in Lusaka are linked with the Kampala-based TB Supranational Reference Laboratory for second line anti-tb drugs testing, and a treatment program is in place. Communities form an integral part of systems which pro-actively contribute to key national development goals and improved health outcomes of their members. Community-based volunteers such as adherence support workers (ASWs), TB supporters and safe motherhood action groups (SMAGs), among others, have made significant impact in increasing the uptake of health services. The (draft) National Health Strategy commits to providing more space to communities to develop and implement innovative approaches based on synergies and referral linkages between health and community systems. However, the absence of a community health strategy that clearly defines community health is a hindrance. This is compounded by inadequate numbers of qualified staff deployed in primary health care facilities, high drop-out rates of community-based volunteers, and volunteer incentive schemes that are not harmonized. Two training schools for community health assistants (CHAs) have been established, but by 2016 only 1577 CHAs had graduated against the targeted Further, service delivery at community level has been affected by non-availability of reliable transport for patient referral. While Neighbourhood Health Committees and Health Centre Committees exist in 84% of the health zones, their functionality varies within and across districts. In the area of financial management, achievements include the implementation of the Integrated Financial Management Information System (IFMIS) at MoH headquarters. Funding mechanisms have improved, as transfers are now made directly to the provinces and districts from the MoF/Treasury, reducing audit queries and strengthening internal controls. While noting these achievements, key challenges persist with low and erratic funding to the health sector, fragmented and earmarked donor funding, lack of a Health Care Financing Strategy, low levels of private sector contributions, delayed implementation of the Social Health Insurance Scheme and delays in institutionalization of the 67 National Health Accounts. Lastly, there have been notable achievements in strengthening Zambia s health management information systems (HMIS). The country has rolled out a web-based primary health care system to over 95% of public health facilities and developed a web-based hospital information system which has been rolled out to over 50 hospitals. At the national level, there is a DHIS 2 system which captures data from facilities, and a new community HMIS has been launched to capture community data on the same platform. The DHIS 2 platform has been significantly strengthened through the integration of the TB reporting system and the introduction community reporting modules. The SmartCare patient-level electronic health records system has been rolled out to over 800 (70%) of the ART sites countrywide. However, SmartCare s limited linkages with the TB program and persistent gaps in the quality and use of information signal the need for ongoing trainings and enhanced integration. 22 May

14 1.3 Past implementation and lessons-learned from Global Fund and other donor investments a) List recent disease-specific Global Fund grants from the allocation period and summarize key lessons learned from their implementation. b) Include lessons-learned from specific HSS grants or any HSS investments embedded in the disease-specific grant(s) from the allocation period as applicable. c) Outline lessons learned from investments by other donors as applicable. For each of the above, explain how these lessons learned are taken into account in this funding request. Several important program, strategy and impact reviews have been recently conducted which reveal critical areas for evolving and refining Zambia s HIV, TB, and related health systems responses. This funding request is cognizant of these findings and directly responds to identified gaps and opportunities. Key lessons learned from Zambia s two active HIV and TB Global Fund grants from the funding cycle (ZMB-C-CHAZ and ZMB-C-MOH), cross-cutting Global Fund RSSH investments, and the investments of other funding partners are summarized below. These lessons necessarily guide and inform the strategic direction of this funding request. Lessons Learned from Current HIV Global Fund Grant Implementation There are many critical lessons in the (draft) end-term review of the revised National Strategic Framework on HIV and AIDS ( ) (Annex 4, pg. xii-xiv) - which the current Global Fund grant is invested in support of. In addition, there are several more specific lessons learned from program implementation: Community-level treatment adherence support reduces loss to follow-up and increases VLS Through phone, SMS and home visits, community adherence support workers (ASWs) in Zambia s current grant have led to steady increases in the number of PLHIV accessing and staying on treatment, increasing viral load suppression. Figure 11 highlights the drastic increase in loss to followup which occurred at the end of 2011, after support to ASWs was terminated following uncertainties with Global Fund funding (cancellation of Round 11). The number of people retained in care fell from 52,371 to 27,527 over the space of six months. After discovering this dramatic effect, reprogramming in mid-2012 reinstated the ASWs. The return to care and improved retention after this action is clear. Figure 11: Impact of Adherence Support Workers (ASWs) on Retention in Care (CHAZ Program Data) Effect of discontinued support to ASWs Effect of reinstated support to ASWs No. PLWHAs on ART Q2 Y 2006 Q3 Y 2006 Q4 Y 2006 Q1 Y 2007 Q2 Y 2007 Q4 Y ,771 44,134 46,571 48,817 50,561 52, Q1 Y 2008 Q2 Y 2008 Q3 Y 2008 Q4 Y 2008 Q1 Y 2009 Q2 Y 2009 Q3 Y 2009 Q4 Y 2009 Q1 Y 2010 Q2 Y 2010 Q3 Y 2010 Q4 Y 2010 Q1 Y 2011 Q2 Y 2011 Q3 Y 2011 Q4 Y 2011 Q1 Y 2012 Q2 Y 2012 Q3 Y 2012 Q4 Y May

15 Social cash transfers for AGYW improve school enrolments and reduce HIV risk behaviour Cash transfers have been shown to have significant impact on reducing new HIV infections among 68 AGYW, primarily by keeping girls in school. In Zambia, a randomized control trial of the national social cash transfer program found that while many of the girls in the control group stopped enrolling in school, the cash transfer program helped girls maintain their enrollment in school, with an 8 percentage point impact. The Zambia Child Grant Programme (CGP) and the Zambia Multiple Categorical Grant (MCP) have also been shown to impact enrolment rates of secondary school age 69 children by 9 and 12 percentage points, respectively. In 2016, a survey found that Zambia s national social cash transfer program was also associated with significant increased condom use and condom negotiation skills (when combined with the use of adolescent health structures and improved condom supply and distribution) (Figure 12). Based on these positive lessons, the Ministry of Community Development and Social Welfare aims to scale the social cash transfers program to 500,000 households in The preliminary roll-out of a new Global Fund-supported cash transfer pilot program called Adolescent Girls Accessing Prevention and Education (AGAPE) (implemented by CHAZ) is showing early promise for increased impact. Figure 12: Change in Adolescent Condom Use and Condom Negotiation Skills as a Result of 70 an Adolescent Health Intervention, Including Social Cash Transfers, in Zambia (MoH/UNICEF) 58% 47% 45% 64% 61% 61% 50% 35% Males Baseline (Dec 2015) Females Endline (July 2016) Adolescents who report using a condom at last sex Males Baseline (Dec 2015) Females Endline (July 2016) Adolescent who said they had asked a recent partner to use a condom before sex Adaptive leadership approaches are needed to reduce HIV Incidence among AGYW Lessons learned from current implementation show that even as significant progress is noted in many areas of improving national health outcomes in Zambia, existing strategies are not going far enough to reduce stubbornly and disproportionately high HIV prevalence and incidence among AGYW (1524). Acknowledging this, the country has embarked on the development of an adaptive strategy for HIV prevention in AGYW. Specifically, the lessons show that current implementation is not succeeding in achieving cultural and value shifts, collaboration is weak, and work is often done in silos. The holding environment for adolescent youth is not adequately nurturing, and the levels of dialogue and involvement of adolescents in the design and delivery of peer education is too low. This funding request prioritizes innovative and flexible interventions for AGYW in line with the new adaptive framework. It also prioritizes training community-based organizations (CBOs) and civil society organizations (CSOs) in the adaptive leadership approach, to catalyze impact. Prioritizing mobile outreach to perform VMMC significantly increases coverage against targets Implementation data from CHAZ shows that VMMC coverage against their program targets was 52% in 2015, 97% in the first semester of 2016 and 120% in the second semester of This significant improvement is largely attributed to the commencement of targeted mobile outreach in 2016, through VMMC campaigns in schools and communities, including mobile service delivery. Indeed, the VMMC Operational Plan ( ) notes that Lessons learnt are that community engagement through its established structures before service delivery is initiated is a must. Other lessons learned include the value of VMMC champions, using weekly indicators and reporting to track performance, quality assurance mechanisms and the innovative use of information and communication technology (the creation of the a VMMC WhatsApp group for the VMMC sites). 22 May

16 In addition, lessons from MoH show that VMMC campaigns conducted in April, August and December every year using both facility-based and outreach services coupled with geographic targeting have helped reach nearly 1.5 million adolescent boys and men since 2007 (Figure 13). For instance, over 60% of the VMMCs done in each year are done during these campaign months. Further, involvement of traditional leaders and sustained demand generation for VMMC has improved uptake of VMMC in the country. But, while the Ministry has learned that the service has been widely accepted, including the traditionally non-circumcising regions, the coverage has been geographically uneven (Figure 14). Figure 13: Cumulative VMMC Program Performance (MoH Program Data) Figure 14: Males Circumcised (% of all males), by Province (2016) 71 Integration of HIV and cervical cancer can reduce mortality among women living with HIV In 2016 the Global Fund began supporting Zambia s national HIV/cervical cancer integration efforts. Zambia s cervical cancer prevention program has demonstrated the lessons learned that linking cervical cancer screening and HIV services is a cost-effective way of improving health outcomes of women living with HIV. The program was integrated into the existing HIV program, leading to an expansion of cervical cancer screening to more than 100,000 women (28% of whom were living with 72 HIV) over a period of five years. The Zambian cervical cancer program, together with the HIV and TB programs and bilateral partners, has opened 58 cervical cancer screening clinics in 41 districts, targeting women living with HIV across the country. The program uses a See and Treat approach using VIA. Women who are screen positive are immediately treated within the same visit if eligible. Lessons from implementation show that this reduces loss to follow-up in women needing treatment for pre-cancerous lesions. Those with complex cervical lesions are referred to the cervical cancer 22 May

17 screening referral clinic. There are 25 cervical cancer referral clinics countrywide based in the public health facilities. Most of the women are seen within one week of referral. This adaptive response has leveraged resources from multiple partners while enhancing coordination and integration of HIV and 73 cervical cancer. The new integrated program is on track to reduce incidence and mortality from cervical cancer by 25% by 2025, particularly among women living with HIV. Integrated sample transport and point-of-care services can improve early infant diagnosis A recent review found that the long turnaround time for early infant diagnosis (EID) tests hampers the country s ability to expand testing coverage and scale-up paediatric treatment. According to the review, the average turnaround time for dry blood spot (DBS) tests for early infant diagnosis was 70.6 days. The longest delay within the process is the transport time, which was shown to take an average of 44 days to move from the facility to the district for processing. Transport systems used are postal 74 services, health facility motor vehicles, courier services and motor bikes. As a result of sample transport challenges (among others), just 54.5% of exposed infants were tested in The country has ambitious EID testing scale up plans, with a target of 95% by 2020 in the integrated Viral Load 75 and Early Infant Diagnosis Testing Scale-up Implementation Plan ( ). In light of these lessons, strategies to improve this situation include ensuring there is continuous distribution of DBS collection kits to sites, increasing the number of testing centres, and integrating the sample transport system for viral load and EID tests. Part of optimizing the use of the 12 existing viral load machines in the country is to expand DBS testing for EID. This funding request prioritizes investments in Prong 4, particularly improving EID, as the top priority for the country s efforts to achieve validation of elimination of vertical transmission (emtct). Laboratory investments also keenly prioritize POC. Lessons Learned from Current TB Global Fund Grant Implementation There are several important lessons learned in the WHO s recent (November 2016) end-term review of Zambia s National TB and Leprosy Control Strategic Plan (Annex 5) which the current Global Fund grant is also invested in support of. In addition, there are several more specific lessons learned from program implementation: Optimizing the use of GeneXpert will help close the gap in finding missing TB cases Lessons from the implementation of the current Global Fund TB grant shows that insufficient access to health care combined with low TB suspicious index among health workers contributes to the 40% gap in TB case notifications more than 27,000 missing cases in According to the Rapid Performance Assessment for Xpert MTB/RIF in Zambia (April 20 May 5, 2016), the introduction of 76 GeneXpert has already shown increases in TB case detection among PLHIV. Recently, the NTLP has moved to recommend the use of GeneXpert as the primary diagnostic method for all presumptive TB cases. However, the physical location of many centers means they are not equitably distributed in the provinces. This funding request supports the commitment in the new (draft) TB NSP (Annex 2) to establish an integrated courier system, mitigating unequal access to the culture facilities. Community systems and responses are underutilized in TB care and prevention While the HIV program has significantly improved as a result of effective civil society and community responses, the TB program has not commensurately benefitted. The absence of a clear community TB care and prevention strategy has been a missed opportunity for increasing case notifications and decentralizing treatment to the community level. Further, the limited involvement of other stakeholders in the planning and provision of TB services - particularly traditional medical practitioners and CBOs contributes to low case detection, adherence challenges and loss to follow-up. Responding to these lessons, the NTLP intends to develop a community volunteer package, including standard remuneration. This funding request proposes significant investments in strengthening community responses and systems to build platforms for enhanced TB (and HIV) care and prevention at community level. Training health workers and updating approaches can improve MDR-TB treatment success Zambia s low MDR-TB cases notifications are largely related to inadequate knowledge among health workers. Without any initial MDR-TB training, health workers have not been identifying many presumptive cases. Further, although GeneXpert machines were introduced in 2012, the national guidelines until end of 2016 did not allow all RR-resistant patients to start MDR-TB treatment unless a full DST result was available. This created significant delays in treatment initiation, increased 22 May

18 transmission in communities, and caused many patients to die unnecessarily. Compounding this, contact investigation was not a routine practice. For those who were diagnosed, the centralized nature of programmatic management of drug resistant tuberculosis (PMDT) negatively affected enrolment and treatment success rates. Based on these lessons learned, the NTLP has changed its approach. It has now begun training health workers on MDR-TB allowing provincial hospitals to initiate patients on MDR-TB treatment, arranged a courier system for transporting sputum to GeneXpert sites, and now treats all RR-ref cases as an MDR-TB, in line with the most recent WHO guidelines. The NTLP has also launched an ambulatory model of care and is planning to introduce a shorter regimen for MDR-TB treatment. This funding request is in support of rolling out the NTLP s updated approaches, aiming to significantly improve the MDR-TB treatment success rate from the 30% baseline (2013) to above 80% by the end of the current NSP. Treatment success will be further enhanced through the introduction of MDR/RR-TB shorter regimen. Lessons Learned from Embedded RSSH Interventions in Current Global Fund Grants In addition to the two end-term strategic reviews for the HIV and TB programs, the recent (2017) midterm evaluation of Zambia s current Global Fund program (Annex 6, pgs. 13; 25-26) identifies some additional key gaps and lessons learned from implementation, particularly relating to crosscutting RSSH aspects. The mid-term review of implementation and performance of the revised National Health Strategic Plan ( ) (Annex 7) provides some additional lessoned learned. Pertinent lessons in RSSH which guide and inform this funding request include: Investing in human resources for health will improve rural access and quality of care While Zambia has increased the total number of health workers (both clinical and administrative support staff) from 29,111 in 2010 to 36,636 in 2013 a 28% increase a large unmet staffing gap 77 persists. In 2016, there was a 32% gap (20,427 posts) between the current staffing levels and the established sector estimated need (recall Table 2 for HRH gaps, disaggregated by cadre). The midterm review of the National Health Strategic Plan ( ) confirms the need to accelerate the recruitment of HRH, to meet the staff establishments. Further, a recent (2015) Community Health Assistant (CHA) Program Process Evolution Report published by CHAI and the Ministry of Community Development, Mother and Child Health, found that CHAs play a critical role in the communities, 78 providing a wide range of preventive, basic curative, and referral services. Similarly, the involvement of TB treatment supporters at community level in the current grant was translated into increased active case detection of TB, adherence to TB treatment and referral from communities to facilities. As an important policy option for strengthening health systems and delivering health services directly to rural communities, expanding this cadre should be prioritized. Indeed, filling essential staffing gaps is a top priority for this funding request (see RSSH matching funds request, where expansion of community health workers has been prioritized). This is to complement the existing investments in infrastructure and program expansion from the government of Zambia. Weaknesses in the procurement and supply chain limit access to essential medicines In order to achieve universal coverage of HIV and TB treatment, improvements to the procurement and supply chain must be prioritized. Lessons from current implementation shed light on the gaps, particularly around forecasting, planning and quantifications. A key lesson learned is that there has been inadequate reporting due to multiplicity of reporting systems, as well as inadequate human resources for health. Facilities have had gaps in reporting and requisition. For instance, access to commodities differs depending on which programme the facility is currently a part of (Essential Medicines Logistics Improvement Program (EMLIP) vs. kits) and inadequate data visibility, often 79 disconnected from warehouse inventory, resulting in challenges in quantification. Indeed, examples of artificial stock outs of health commodities have been reported. To remedy this and respond to these lessons, this funding request specifically prioritizes strengthening the PSM, especially around coordination of partner contributions, forecasting, budget release, procurement, storage, distribution, monitoring and evaluation. Investments in good financial management information systems improves accountability CHAZ has seen significant improvements in reporting and accountability upon scaling up the use of the SUN accounting system. They have also extended the reporting templates to their sub-recipients. This has delivered significant value-add for the management of Global Fund grants in Zambia, creating more clarity around implementation progress and enabling consolidation of data from Global 22 May

19 Fund investments back into the expanded financial report (EFR), so that it can be reported at global level. In addition, there are also IFMIS lessons learned from MoH - and perhaps on a larger scale. As a result of identified challenges with paper-based methods, the MoH plan is to move to the Navision software for all districts and facilities under the government-managed grant (as well as those supported by CHAZ, as part of national policy). The interventions prioritized for FMIS in this funding request support this move, in light of lessons learned by both CHAZ and MoH. Lessons Learned from Investments of Other Major Funding Partners Differentiated HIV testing services improves yield and suggests the first 90 is possible While there are many important lessons from a wide variety of country partners, the most pertinent for this funding request is on differentiating HIV testing services (HTS). Modeling done by the Clinton Health Access Initiative (CHAI), PEPFAR s HTS program, and the PopART trial reveal that differentiating HTS can further optimize Zambia s HIV budget, increase value-for-money (by focusing on high yield approaches) and expand coverage (towards the first 90 ). CHAI modeling shows that a 80 more optimal HTS mix could generate savings of more than $15 million over From PEPFAR HTS program data (Figure 15) index testing emerges as the method with the highest yield, particularly for people over the age of 25. Index testing and facility-based testing may be best approaches for AGYW, while facility-based testing has the highest yield for young men. Figure 15: PEPFAR Zambia Data on HIV Test Volume and Positivity Yield (%), by Age and Sex 81 Recent results from the first round of the PopART trial in Zambia (December 2013 to June 2015) show that a universal testing and treatment intervention that includes home-based HIV testing delivered by community HIV-care providers (CHiPs) has the potential to dramatically improve knowledge of HIV-positive status, almost attaining the first 90 target in women and approaching it in men. In the first year of the trial, the estimated proportion of HIV-positive adults who knew their status 82 increased from 52% to 78% for men and from 56% to 87% for women. Limited partner coordination for co-funded activities can stall implementation In many of Zambia s HIV, TB and RSSH programs, there is joint-funding from multiple partners, including Global Fund, the United States Government, among others. This is often an effective way to leverage additional resources for aspects of the response where there are large funding gaps, such as ART, PSM, among others. However, lessons from implementation have revealed that this joint funding is often poorly coordinated. As a result, the late release of budgets for procurement from some partners has, in the past, resulted in a shortage of ARVs. The limited communication and coordination among partners means that these gaps are often not filled in a timely manner. This flags the need to invest in improved coordination structures, like the PSM technical working group (PSM TWG), joint planning across the HIV and TB programs, among other platforms. This funding request prioritizes investments in these kinds of coordination structures to improve cohesion of investments form multiple partners. 22 May

20 SECTION 2: FUNDING REQUEST (Within Allocation) This section should describe and provide a rationale for the program elements proposed for this funding request. Attach and refer to completed Programmatic Gap Table(s), Funding Landscape Table(s), Performance Framework and Budget, and refer to national strategy documents as applicable. To respond, refer to additional guidance provided in the Instructions. Ensure that the funding request as described in questions 2.1 and/or 2.2 meets the focus of application requirement as outlined in section Disease-specific funding request Given the context and lessons learned outlined in Section 1, a) Describe the disease-specific funding request(s), the rationale for prioritizing modules and interventions, and how these choices ensure the highest possible impact with a view to ending the three diseases and removing human rights and gender-related barriers to accessing services. For any priority modules for which gaps are difficult to quantify in the programmatic gap tables, explain here the barriers being addressed, the proposed interventions and the population or groups involved. b) Explain how the funding request addresses the key funding gaps reflected in the Funding Landscape Table(s) for the disease program(s) in the current allocation cycle, and specify other actions planned to cover remaining gaps. For funding requests including both HIV and TB components: a) Describe the coordination of joint TB and HIV strategies, policies and interventions at different levels of the health system, including community systems, and expected impact and efficiencies from the joint programming. This funding request represents a targeted investment within a comprehensive response. Based on a full review of the country s approach and strategic priorities, the requested investment harnesses disease and systems-related opportunities to maximize impact and value-for-money. As highlighted in Section 1.2, the thrust of this funding request is threefold: (1) Further optimize the country s HIV and TB budgets through allocative and technical efficiency factors; (2) Reduce gender and age-related disparities and close gaps among key and vulnerable populations; and (3) Create a more sustainable HIV and TB response by engendering flexible and adaptable patient-centred systems for health. This investment is anticipated to support the achievement of the following top-line goals: Avert 80,000 new HIV infections over This could save up to $21.2 million by 2020, in terms of treatment costs alone (NASF modelling) Avert 43,000 AIDS-related deaths over , reducing morbidity costs to the health system, loss of production income to the country and importantly reducing the impact on family well-being, specifically children (OVC reductions) (NASF modelling) Reduce the number of TB deaths in the population by 40% in 2021 compared to 2015 Zambia has prioritized the HIV and TB modules based on their evidence-based efficacy and their potential contribution to the reduction of new infections and deaths. Particular attention was given to prioritized modules and interventions which will increase access and utilization of services by key and vulnerable population groups. Table 3 provides an overview of the prioritized funding request, presented by module and intervention. 22 May

21 Table 3: Summary of Zambia s TB/HIV/RSSH Funding Request, by Module and Intervention Module/Intervention Treatment, Care and Support Differentiated ART service delivery Treatment monitoring - Drug resistance surveillance Treatment adherence Treatment monitoring - Viral load Sub-Total Prevention Programs for Adolescents and Youth, in and out of school Behavioral change as part of programs for adolescent and youth HIV testing services for adolescents and youth, in and out of school Linkages of HIV, RMNCH, and TB programs for adolescents, girls, and young women Other intervention(s) for adolescent and youth Community mobilization and norms change Gender-based violence prevention and treatment programs for adolescents and youth Sub-Total Prevention Programs for General Population Condoms as part of programs for general population Male circumcision Sub-Total Prevention programmes for other vulnerable populations Behavioural interventions for other vulnerable populations Other intervention(s) for other vulnerable populations Sub-Total HIV Testing Services Differentiated HIV testing services Sub-Total PMTCT Prong 3: Preventing vertical HIV transmission Prong 4: Treatment, care and support to mothers living with HIV, their children and families Sub-Total TB Care and Prevention Case detection and diagnosis Treatment Engaging all care providers (TB care and prevention) Key populations (TB care and prevention) - Others Sub-Total MDR-TB Treatment: MDR-TB Key populations (MDR-TB) - Others Sub-Total TB/HIV TB/HIV collaborative interventions Community TB/HIV care delivery Sub-Total RSSH Community responses and systems Financial management systems Human resources for health (HRH), including community health workers Procurement and supply chain management systems Health management information systems and M&E Integrated service delivery and quality improvement Sub-Total Program Management Grant management Sub-Total TOTAL Amount (USD) $92,345,482 $150,000 $4,474,611 $46,859,803 $103,829,895 $1,117,895 $7,547 $3,114,958 $1,632,947 $445,263 $315,789 $6,634,400 $3,060,915 $6,069,508 $9,130,423 $1,276,484 $74,126 $1,350,611 $4,588,475 $4,588,475 $518,400 $2,910,225 $3,428,625 $924,709 $3,933,282 $61,309 $418,960 $5,338,261 $3,879,581 $273,158 $4,652,739 $7,645,692 $42,017 $7,687,709 $3,072,633 $600,000 $12,091,074 $5,464,884 $2,490,285 $450,000 $24,168,876 $17,218,255 $17,218,255 $194,386, May

22 Module: Treatment Care and Support The top priority in this funding request is to support the scale-up of ART, towards universal coverage. Funding is requested for the procurement of adult and paediatric ARVs. Averaged over the implementation period, approximately 18% of Zambia s adult ARV costs will be covered by domestic resources, with a further 41% covered by PEPFAR. Therefore, funding is requested to fill the remaining 41% gap. For paediatric ARVs, the gap is much smaller. 29% are covered by the government of Zambia, and 63% by PEPFAR, leaving just 8% of the total need included in this funding request. This proposed investment will contribute to the achievement of the national target in the NASF to have 955,810 adults and 41,201 children on ART by 2020 (Annex 1, pg. 42). Importantly, Zambia has moved to implement test-and-start as national policy as of November This is anticipated to lead to increased patient load, which necessitates the move to differentiated care - which this investment will support. Zambia s differentiated care model includes decentralization of ART to community pick-up points, with innovative refill strategies (i.e. community refill groups). Stable patients will be able to collect 6 months ART supply, available through non-physician prescribers as part of task-shifting. Higher-risk patients will continue to receive regular attention. This proposed investment will also support increased access to viral load testing. In line with the country s Viral Load and Early Infant Diagnosis Testing Scale-Up Implementation Plan , Zambia aims to perform nearly 3 million viral load tests during the implementation period 83 (745,118 in 2018, 974,720 in 2019 and 1,232,533 in 2020). Specifically, funding is requested to procure point-of-care (POC) viral load/eid machines and related reagents, paired with quality assurance interventions. This funding request prioritizes POC VL/EID to complement the investment of the government and other funding partners in decentralizing VL/EID testing. This is also prioritized based on the preliminary results of an ongoing viral load optimization analysis in the country, which shows the combination of decentralized VL/EID and scale-up of POC services to be the most costeffective model. In the Copperbelt, this combined model can reduce the cost per viral load test to 84 $33.10, as compared to $35.93 with all POC, $33.23 with all referral labs. To support viral load suppression and decrease mortality, targeted adherence support and community tracing through ASWs is prioritized to improve VLS among people on ART. This will be prioritized for young people and men in particular, as the recent ZAMPHIA data shows that these groups have lower VLS and may require targeted and tailored adherence support (Figure 16). Figure 16: Viral Load Suppression among HIV-Positive People, By Age and Sex 85 The rationale for including community tracing in this request is based on evidence from Zambia that it has a cost-effective impact on increasing retention in care. National guidelines recommend a combination of phone calls and home visits for patients lost to follow-up. One Zambian study found that successful community tracing led 23.8% of those lost to follow-up to return to clinic and HIV care, 86 increasing retention at 1-year from 80.9% to 82.8%. Recall from Section 1.3 that lessons learned from program data also supports the rationale for investing in community adherence support workers. Note: See attached matching funds request for integrated HIV/TB/cervical cancer activities, catalyzing impact of investments in HIV treatment by reducing mortality among WLHIV. 22 May

23 Module: HIV Testing Services As noted in the country context section, the testing gap of 32.7% among people with HIV who do not know their HIV status (Recall Figure 5), and poor coverage among men, key populations and young people in Zambia, are key challenges. As the second-most pressing priority following scale-up of ART, funding is requested to procure standard test kits and support differentiated HTS delivery, prioritizing high yield approaches such as provider initiated testing and counselling (PITC), index and couples testing. Emphasis will be placed on targeting key populations and geographic hotspots, and using HTS as an entry point for other integrated prevention (ANC, VMMC, PMTCT and TB screening). In line with the country s current HTS implementation plan, approximately 50% of HTS will be through static sites, 40% through local outreach and 10% through long-distance outreach. The success of the top priority module in the request (ART) critically depends on the effective scale-up of HTS. Given that the country aims to initiate 147,899 new patients in 2018, 151,948 in 2019 and 155,922 in 2020, the HTS scale-up required to enable these initiations is clear. In 2020, 7 million tests will need to be conducted to reach ART initiation targets; over two times the number conducted in Procurement of HIV self-testing kits is prioritized in the above allocation request, with a view to support phased implementation of HIV self-testing services going forward. Recalling that one of the critical opportunities of this funding request is to further optimize the budgets of the HIV (and TB) program through technical and allocative efficiencies, the funding requested for HTS is also geared towards realizing added savings through the proposed best mix of differentiated HTS strategies (as per the HTS implementation plan). The modelling that guides the plan (recall the lessons learned from CHAI modelling in Section 1.3) demonstrates that more than $15 million in savings can be realized through allocative efficiencies among various differentiated HTS methods (Figure 17). Over , the optimization largely depends on expanding access to couples testing. The requested funding will prioritize elevating influential people within social networks to raise awareness of the importance of joint HIV testing for couples, as evidence shows this is an effective 87 way of scaling up couples testing. 88 Total Number of Tests (Thousands) Figure 17: Baseline Scenario (Left) vs. Optimized Scenario (Right) on Differentiated HTS Mix Baseline HTS Mix Scenario Optimized HTS Mix Scenario VCT PITC: ANC PITC: Couples PITC: TB PITC: VMMC Door to Door 0 Campaign Module: HIV Prevention Programs for Adolescents and Youth, in and out of school For HIV prevention, the national strategy is to focus where the need is greatest and the largest impact can be made. For Zambia, the top priority group for HIV prevention is adolescent girls and young women, while including support to young men and boys. This is clearly supported by the epidemiology, since HIV prevalence is more than four times higher among young women (8.6%) as 89 compared to their male peers (2.1%). However, the need to focus on adolescent boys is equally supported by the data: A trend analysis of DHS surveys shows that while HIV prevalence among adolescent girls fell between 2007 and 2014, prevalence rose among adolescent boys over the same 90 time period. Funding is requested to deliver a six-pronged comprehensive package of health and empowerment programs for adolescents and young people, with an amplified focus on AGYW. The six prongs include interventions around: (1) Social and behavioural change communication (SBCC) and 22 May

24 comprehensive sexuality education (CSE); (2) Adolescent-friendly service provision; (3) Socioeconomic support (cash transfers and school support); (4) Research and implementation science; (5) Adaptive leadership; and (6) Coordination and youth engagement in design and delivery of programs. The SBCC prong will support age-appropriate delivery (grouped in age brackets of 10 14, and 20 24) of life skills and CSE through peer educators groups. For in-school adolescents and youth, funding will support teacher training around the existing national CSE curriculum, spearheaded by the Ministry of Education. For out-of-school adolescents and youth, peer educator groups set up by 91 CSOs/FBOs will use the new out-of-school CSE curriculum (see Annex 8). Using the Tune-me, U92 93 Report and Tikambe platforms, a wide range of SRHR, HIV/STI/TB treatment and care and GBV information will be disseminated, including linkage to care. The program will also support the promotion and distribution of male and female condoms targeting adolescents and young people, through social marketing, social media platforms and mass media. This responds to the findings of Zambia s DHS, which found that while HIV testing went up among adolescents, reported condom use and teenage pregnancy rates did not change. For the service provision prong, funding will support interventions aimed at strengthening the quality of services and increasing access to adolescent and youth-friendly SRH/HIV/STI, GBV and psychosocial services. These services will include access to contraceptives, increasing the uptake of HTS, VMMC, ART, condom use, STI screening, TB treatment, among others. In particular, funding will support the scale-up of current models which create safe spaces for adolescent girls, in line with the Adolescent Health Strategy. Importantly, this activity aims to ensure that young people will be able to access youth-appropriate HIV services in the areas where they study or live, especially where there may not be a functioning adolescent health services platform. Note: See attached matching funds request for socio-economic activities to keep girls in school. The research component will build on existing Legal Environment Assessment (LEA) operational research to understand how the legislative environment can play a role in influencing HIV and SRHR services utilization efforts in favour of adolescents and young people, particularly AGYW. To support the roll-out of the new adaptive leadership framework (recall Section 1.3), funding will support the training of AGYW and youth-focused organizations (CBOs/FBOs) in adaptive governance and leadership. It is anticipated that this will facilitate higher-impact community-based activities while strengthening accountability systems for adolescent and youth HIV/SRHR programming at all levels. Lastly, funding will support increasing dialogue and involvement of adolescents in the design and delivery of their programs, as emphasized in the government s youth policies and the adaptive leadership framework (recall section 1.3). Funding will support the organization of national youth networks as well as national annual forums and monthly and quarterly Technical Working Groups (TWGs) for services providers and beneficiaries to share experiences and lessons learned. 1 This investment will be geographically targeted to complement PEPFAR s DREAMS program (in (Chingola, Chipata, Kabwe, Kapiri, Kitwe, Livingstone, Lusaka and Ndola) and the government s Girls Education and Women s Empowerment and Livelihood (GEWEL) project (some activities are in 11 districts, others in 51). Concerted coordination efforts will be necessary throughout implementation. Module: HIV Prevention Programmes for other Vulnerable Groups In addition to adolescents, other key populations for HIV prevention include those defined in the NASF (Annex 1, pg ), as explicitly named in the country context section of this proposal. Funding is requested to support the growth of the already-established key and vulnerable populations pooled fund. The rationale for the pooled funding is strategic within Zambia s current legal and policy environment. This will contribute towards NASF targets to decrease HIV prevalence among prisoners, from 27.4% at baseline (2011 IBBS) to below 15% by 2021, and among female sex workers, from 56.8% at baseline (IBBS, 2015) to less than 10% by 2021 (Annex 1, pg. 81). 1 One possible implementation approach (proposed by PEPFAR Zambia) would be to channel Global Fund resources to the same 8 districts where PEPFAR is implementing DREAMS, but to work in defined zones (facility catchment areas) that are not part of the PEPFAR program. The intention would be to maximize saturation of the highest-burden districts while minimizing coordination risks. This approach could enhance impact against shared district-level targets for reducing AGYW HIV incidence. 22 May

25 In line with the most recent global technical guidance (the MSMIT, SWIT and IDUIT ), this funding request will support the differentiated delivery of peer-led comprehensive health and empowerment programs, combining community empowerment, addressing violence, distributing condoms and lubricants, taking a harm reduction approach, providing integrated HIV/TB/STI health services, offering legal support, and making creative use of information communication technology. This will be done through a community-led peer-education approach with strong linkages to care, via flexible and differentiated service delivery models (fixed sites, mobile sites, moonlight services, etc.). For prisoners and mineworkers, enhanced HIV/TB collaborative activities will be prioritized. Module: HIV Prevention Programs for the General Population While the strategy for Zambia is to prioritize populations most-at-risk, HIV prevention services are also necessary for the general population, to achieve epidemic control. This funding request strategically prioritizes VMMC and condom programming as the highest-impact, most cost-saving interventions. First, funding is requested to support front-loading investments in VMMC, towards saturation levels among men (10-29). This will be done through community outreach and targeted demand creation (recall lessons learned). A small portion of the funding will also support foundational 97 preparations (i.e. trainings) for moving to EIMC, in line with the country s operational scale-up plan. This investment will cover 51% of the national funding gap, with the remaining 49% in the prioritized above allocation request. Over , Zambia aims to circumcise 1,135,041 men. This proposed investment will support 84,143 of those procedures. Modelling suggests that by front-loading investments in VMMC, impact will be increased and costs will be reduced in the longer-term (Figure 18). If VMMC spending is front-loaded and optimized (the blue line in Figure 19), this will contribute to 98 a 7.6% decrease in cumulative new HIV infections compared with a constant funding scenario. Figure 18: Added Impact and Cost-Saving by Front-Loading VMMC Investments in Zambia 99 Funding is also request to procure condoms and lubricants, and improve effective distribution, programming and monitoring. While UNFPA has traditionally funded large-scale condom procurement in Zambia, recent changes in the funding landscape mean this supply is less reliable. Education and awareness on consistent and correct use will be intensified among key groups. Gender-transformative condom negotiation skills for AGYW will be prioritized, since just 40% report 100 the use of a condom at last sex. Community-driven demand creation will be accelerated in risk 101 hotspots, with evidence from Zambia showing location-targeted strategies to increase condom use. Part of this targeting will include integrating condoms services into non-hiv health programs. Improving condom distribution channels is a key catalyst for this program. While Medical Stores Limited (MSL) does condom procurement, there is a need to improve last-mile distribution. An existing model that is showing promise is prioritized, including training community-based distributors in logistic management, so they can keep inventory lists and distribute condoms within their communities. 22 May

26 Module: Prevention of Mother-to-Child Transmission Zambia s prevention of mother-to-child transmission program is relatively mature, historically benefiting from advanced health worker trainings and significant investments from country partners. However, Zambia is working towards elimination (less than 2% by 2020), which will require infused investments. Funding here is prioritized to: (1) Support early presentation at ANC for pregnant women, and (2) Improve EID. For the first priority, funding is requested for Prong 3, supporting pregnant women to present earlier for ANC. At present, many pregnant women are presenting very late to facilities. For instance, the DHS shows that only 24% of women have their first ANC visit in the first trimester of 102 pregnancy. This builds on existing Global Fund investments in community-level PMTCT interventions, including the safe motherhood action groups (SMAGs). In addition, funding is requested for Prong 4, addressing the long turnaround time of EID tests and the low treatment initiation rates among exposed infants. This will be done by strengthening the integrated sample transport system (VL, EID and TB samples) and maximizing use of VL machines to do DBS EID testing, reducing the current 70+ days turnaround time (recall lessons learned). Further, linkage to care for exposed infants will be prioritized, given that only about 50% of those who test positive are currently put on treatment. Zambia also plans to integrate EID into the country s vaccination program to increase access. In addition, recall from the Treatment Care and Support module that the investments in POC EID will also help to address these EID gaps. SMAGs will also be used to trace mothers of exposed infants to encourage them to present at facilities for EID, upon receipt of results through the SMS printers. The rationale for only prioritizing Prongs 3 and 4 in this module is based on the logic that activities under Prong 1 are covered under the condom interventions as well as treatment interventions (through treatment as prevention). Activities under Prong 2 are covered with the investments in integrated HIV/SRHR activities under the prevention programs for adolescents and youth module. Module: TB/HIV Collaborative Activities Though there are major achievements in reducing the burden of HIV among TB patients, measures to reduce the burden of TB among PLHIV has been much slower. In 2015, IPT coverage among PLHIV was low (15%), as was ART coverage in TB/HIV co-infected patients (76%). These gaps compromise TB and HIV treatment outcomes and in turn increase morbidity and mortality. The top priority is to optimize the use of GeneXpert and further diversify diagnostics for TB among PLHIV. By the end of 2021, the country plans to buy an additional 200 Xpert machines. The recent policy change recommending Xpert as a primary diagnostic tool will alleviate some of the challenges with underutilization, but more machines will be required to meet the anticipated need. Using Xpert Ultra for diagnosing TB in FNA samples, ascetic fluids, CSF and other aspirates will also help to enhance case notification among PLHIV. Further, one Zambian study found that Xpert 103 reduced median number of days to TB treatment among PLHIV by 11 days (from 15 days to 4). A proper courier system for integrated sample transportation will be created. Digital X-rays will be also introduced for childhood TB, as well aid in screening and diagnosis in patients who do not show cardinal signs of TB. Secondly, funding is requested to support the move to a more integrated model of TB/HIV services and care through establishing one-stop-shop centres, paired with community TB and HIV prevention and care approaches. Through these models, funding will support interventions to: (1) Test all TB patients for HIV and screen all HIV patients for TB (2) Intensify case finding and treatment of latent TB infection through use of IPT services in HIV care settings; (3) Support universal access to ART and cotrimoxizole for all HIV+ TB patients; (3) Strengthen TB/HIV community activities; (4) Strengthen clinical and laboratory diagnostic capacity; and (5) Strengthen coordination and joint planning (from national level down to health facilities). Funding is also requested to support joint program reviews at provincial and national level, as well as joint supervision and on-sight mentorship. Importantly, support to community-level health workers and other community-level volunteers will be integrated HIV differentiated care approaches, training, supporting and mentoring these cadres under the same mechanism. 22 May

27 Module: TB Care and Prevention Given that the biggest gap in Zambia s TB response is the high proportion of undiagnosed cases (40%), finding these cases is the top priority for this module. While national targets are to notify 74%, 78% and 82% of TB cases by 2018, 2019 and 2020, respectively, existing resources (domestic and external, including Global Fund), will only enable the program to notify 49%, 52% and 54% of cases over the three years. Additional anticipated investments from the World Bank and through Eradicate TB are expected to cover the remaining notification gap. First, funding will improve diagnostic capacity and scale-up high-yield case finding techniques. Specifically, the proposed investment will support training of health care workers in the updated national TB guidelines. Prospective contact investigation will be prioritized as a way to notify patients, which has proven to be a high yield approach. In addition, retrospective contact screening of TB index patients who completed treatment between 6 month and 3 years will be done, using community-based volunteers. The training of these volunteers will be harmonized through integrated trainings with the ASWs. In facilities, TB screening will be integrated in OPDs, MNCH, family planning, ANC, nutrition, HIV and diabetic clinics. Zambia s draft TB NSP prioritizes deploying OMNI GeneXpert in MNCH. Second, funding is requested to support targeted and intensified TB case finding and prevention interventions among key populations, including prisoners, miners, PLHIV, children, adolescents, TB contacts, healthcare workers, diabetics, and high-density urban residents. In the mining areas, the NTLP will build the capacity of mining hospitals/clinics for periodic screening of workers for TB, their families and introduce contact screening. An urban TB strategy will be designed and contextualized to urban centres. A flexible after working hours and weekend DOTs service will be established to reach more men. A further study will be conducted to identify barriers for accessing TB services. For children, health workers will be oriented on unique features of childhood TB sign and symptoms, strengthen the index TB contacts investigation, and use GeneXpert for diagnosing TB in sputum, gastric and nasopharyngeal aspirates, CSF, FNA and other specimens. TB screening among children will be integrated in RMNCH/nutrition/EPI clinics, with contact investigation as an entry point for IPT. Third, funding will go towards engaging all care providers through a public-private mix (PPM) approach. A mapping of private practitioners in the country will be done, along with development of a PPM handbook to involve all private health providers. Further, the proposed investment will support for a PPM focal person at national level. Orientations to pharmacies and dispensaries on TB screening and referrals will be done, as more than 30% of Zambians use these as a first entry into the system. Traditional healers will also be oriented on TB screening and referrals. Fourth, funding is requested to cover the gap in procuring first-line TB medicines and decentralizing treatment services to communities, leveraging recent gains in improving treatment success rates. With this investment, the country aims to reach 90% TSR among drug-sensitive TB cases, implementing community DOT and differentiated TB care approaches for key populations. This strategy will reduce the travel time and costs for patients and enhance early identification. Health posts and community volunteers will be capacitated to implement community DOT, organizing traditional medical practitioners, CBOs, FBOs and former TB patients to educate and screen households for TB, work in reducing stigma, and serve as treatment supporters for patients. Module: Multi-drug Resistant TB (MDR-TB) The gap in Zambia s MDR-TB response requires urgent and concerted attention, given that the TSR is just 30%. Compounding these poor outcomes, the funding gaps are especially pronounced, with very little external support from other partners anticipated. To achieve national targets to notify 1,200 MDR-TB patients and achieve a TSR of 80% by 2021, funding is requested for several priorities: Funding will support a mixed ambulatory model whereby patients will be initiated on treatment in MDR-TB treatment centres but they will get their treatments in the health facilities closer to the patient s home. Using existing mechanisms, social cash transfers will be given to MDR-TB patients to subsidize nutritional support and transport fees when they visit the MDR-TB centres. Funding will also support the procurement and delivery of both long and new shorter-term MDRTB regimen, following the WHO guidelines. Patients who miss their treatments will be traced by community volunteers or SMS/calls, in line with the TB NSP Lastly, funding will support a drug-resistant TB prevalence survey to allow the country know the true burden of DR-TB in the country. 22 May

28 2.2 RSSH funding request The Global Fund strongly encourages funding requests for RSSH investments to be submitted within a single application, and preferably to be requested in the first submission. Yes Does this funding request include an RSSH component? If yes, describe the request below and how it is strategically targeted. No Referring to the national health strategy, gaps and lessons learned outlined in the previous section, describe the funding request for RSSH and how the investment is strategically targeted to strengthen systems for health and achieve greater impact on the diseases. In your explanation, refer to the Funding Landscape Table on government health spending, Performance Framework and Budget as appropriate. It is optional to complete a Programmatic Gap Table for RSSH. To maximize the impact of the funding requested in the TB/HIV and TB modules above (as well as portions of Zambia s separate malaria funding request) cross-cutting investments to build and strengthen resilient and sustainable systems for health (RSSH) are requested. This RSSH request is aligned to Zambia s (draft) National Health Strategy ( ) (Annex 3) and geared to bolster the strategic plans for the two diseases (Annexes 1-2). Zambia s commitment RSSH is clear in the prioritization of the country s allocation. Zambia has increased the proportion of its Global Fund allocation dedicated to RSSH from 8.4% in the funding cycle, to 12% in the funding cycle. This is higher than the average cross-cutting RSSH investment in Global Fund grants for countries with similar income levels (9.3%). Module: Human Resources for Health, Including Community Health Workers The government of Zambia has continued to demonstrate its strong commitment to addressing the country s human resource for health (HRH) gaps through expanding the staff establishment by approving new structures and providing funding for net recruitments on an annual basis. The health worker s establishment has grown at an average of 5% during the period 2011 to 2016, and the number of nurses in health centres has grown from 12,348 in 2012 to 14,807 in 2016 representing a 4% average yearly increase. However, human resource deficits remain high against the targets in the draft 7th National Development Plan , especially the goal of having 9 nurses per 10,000. Based on identified gaps and opportunities for impact, the top priority for RSSH investment is to increase critical frontline workers in rural areas of Zambia. Specifically, funding will support the recruitment and retention of 600 rural nurses in year 1 of the program. After year 1, the recruited nurses will be gradually transitioned onto the government payroll, absorbed in a staged approach (200 after the first year, 150 after the second year and the remaining 250 at grant close out). Zambia has a good track record of engaging health workers following donor support from CDC, SIDA, DFID, CHAI and JPIEGO. The rationale for prioritizing this intervention is based on the clear discrepancies between the proportions of clinicians in the rural areas against the urban areas, with the most pronounced gap among nursing staff (Figure 19). Recall from Section 1.2 that rural areas are where % of the Zambian population resides and where the burden and mortality ratios are highest. Number of Health Workers Figure 19: Distribution of Health Workers in Rural and Urban Facilities in Zambia ( ) 7,000 6,214 6,000 5,024 5,000 Actual Staff in Rural Facilities 4,000 3,000 2,000 1, Actual Staff in Urban Facilities 1,513 1, Clinical Officers Doctors Midwifes Nurses 22 May

29 In addition, funding is requested to recruit and retain 200 Community Health Assistants (CHAs) in underserved rural areas, to complement the investments in the frontline nurses. Responding to a key recommendation from Zambia s 2015 Community Health Assistant Program Process Evaluation, 107 this will be done in a way that ensures active community participation in the CHA selection process. These CHAs will also supervise and coordinate the ASWs, TB treatment supporters and other community volunteers prioritized in the disease modules. Note: See attached matching funds request for catalytic activities on training and deploying CHAs Module: Health Management Information Systems and Monitoring and Evaluation The health delivery process hinges on health information technology and research, which supports evidence-based decision-making. The second RSSH priority next to rural HRH is to increase the availability and use of data for decision-making, rolling out the DHIS to private health facilities, rolling out of the Hospital HMIS, and rolling out of the disease surveillance modules. Mechanisms to enhance SmartCare interoperability with the DHIS, elmis and the Project mwana SMS system are also prioritized. This activity builds on previous Global Fund investments in improving reporting rates, 108 with over 90% of the health facilities in Zambia reporting data in However, data generated through the HMIS has continued to be underutilized due to perceptions that the data incomplete and of poor quality. Indeed, in 2015, the completeness of source documents for reports submitted by facilities was 58% for HIV and 61% for TB - with more than 10% data discrepancies. To address these shortcomings, the proposed program will provide training to data collectors (from clinicians to enumerators) on standardized processes and procedures for data collection. Accuracy, completeness and timeliness will be assessed through running simple frequencies on the databases, data audits and supplemental data quality surveys. As such, funding is requested to strengthen data quality improvement mechanisms. At the local level, funding is requested to train district staff in Lot Quality Assurance Sampling (LQAS), so they can collect a small amount of data using randomized selection to assess whether programs are reaching program targets or are performing per Ministry of Health standards. This methodology has been used to strengthen data systems for health and countries capacities in over 800 instances and 30 countries. Using LQAS will provide strong local and geospatial estimates of disease burden, linked into DHIS2. This will help programmers identify priority locations to support. Lastly, funding is requested to train 2000 personnel (selected from all cadres from CHAs to program managers) in data visualization and use. Funding is also requested for workshops to enable community data usage. Module: Strengthening Financial Management and Oversight Financial management is an essential element for successful project delivery. Currently, the government of Zambia uses the Integrated Financial Management Information System (IFMIS) as the national financial management system. However, this system only operates at National and Provincial level, with most districts still using Word and Excel for budgeting, accounting and financial reporting. To address this, Zambia is rolling out automated accountancy systems to ensure availability of timely, reliable and accurate financial information, but additional investment is required. Funding is requested to support the roll-out of Microsoft Navision in the remaining districts, training schools, and general hospitals (those not covered by government). Specifically, the investment will support NAV license fees, go-live assistance and on-going support. This will enable districts to provide timely financial reports to the provincial offices, tracking actual expenditures against activity-level work plans. It is anticipate that this will improve both allocative and technical efficiency a central theme of this funding request. This complements investments from other partners, as Zambia is currently implementing Navision at District Offices in two provinces, with support from SIDA and USAID. It will also build on the current Global Fund grant, which is supporting implementation of Navision Enterprise Resource Planning (ERP) software to provincial offices. Second, funding is requested to support the rollout of Routine Enhanced Monitoring System (REMS) in 10 provinces. REMS leverages existing data flows at the national, provincial, district and health facility in generating cost per unit of service delivered in the context of our national response to 22 May

30 HIV, with an option for scalable to other service areas in the health sector. Rolling out REMs will support Zambia to improve expenditure tracking, enhance accountability through greater visibility of healthcare service performance with their associated costs, and stimulate greater investor confidence as system will demonstrate value-for-money. Lastly, funding will support non-state sub-recipients capacity development in financial management. This is informed by lessons learned in this area, presented in Section 1.3. Module: Procurement and Supply Chain Management Systems Strengthening the PSM in Zambia is essential in order to ensure that critical medicines, commodities and health products are available in the right places at the right time. To ensure delivery of health products to health facilities, funding is requested to increase the percentage of health facilities reached with last mile distribution, through the construction of two more hubs in Western (Mongu hub) and North-Western (Kabompo hub) Provinces to provide services in these areas. This will build on current investments where the Global Fund and USAID are providing support to construct stores in Chipata, Choma, Mansa, Mpika, and Ndola (Luanshya). The new decentralized distribution network is expected to see a total of seven regional across the country. Distribution costs are provided in the PSM costs in the list of health products attached. Importantly, the proposed investment to construct these two hubs will unlock an additional $2 million from USAID, which has been promised to support the functionality of these hubs over the next 3 years, once they are built. Second, funding is requested to employ a Procurement Coordinator to monitor partner inputs in procurement planning, financing and execution. This officer will sit at Medical Stores Limited. It is anticipated that through coordination of partners, this post will contribute to increased availability of pharmaceuticals and other health products and reduced waste. Currently, joint partner reviews have highlighted critical challenges in Government procurement financing as well as in coordination of partner contribution to procurement, leading to over-stock and wastage through expiries as well as shortages of HIV/TB supplies. This investment will complement recent national efforts to re-establish a PSM TWG to increase the coordination and allocation of procurement resources in a timely way. Module: Community Responses and Systems Greater emphasis on community responses is a necessity if Zambia is going to end the three diseases as public health threats by In order to achieve the treatment targets, national modelling shows that resources for community mobilization must nearly double from 2016 to 2020, 109 increasing from $4.14 million to $7.51 million. Further, spending on social enablers (including advocacy, law and policy reform and human rights) should reach 8% of total AIDS expenditure in 110 Zambia by To scale up community responses, Zambia prioritizes three key interventions. First, funding is requested to strengthen the capacity of community structures to deliver inclusive and gender responsive HIV/STI/TB/GBV/SRHR/malaria, to meet specific needs of key and vulnerable populations. This will include conducting a capacity assessment of CBOs, NGOs, FBOs and community groups in 30 target districts, documenting and identifying providers to provide capacity development support to improve service delivery. In addition, funding will provide organisation and program support to 60 CSOs in 30 targeted districts. This is a critical action towards expanding community-led service delivery to cover at least 30% of all service delivery by a key 111 commitment in the 2016 political declaration on HIV and AIDS, to which Zambia is signatory. Second, funding will support advocacy for enabling environments and social accountability for marginalized, left out/hard to reach populations and communities. The investment will support community structures in 30 districts to engage with local authorities to prioritize local resources for HIV, TB and malaria, and conduct public social accountability. The UNAIDS Lancet Commission has 112 called on the partners like the Global Fund to invest in activism as a global public good. Third, this investment will enhance community structures monitoring of interventions, including for human rights violations of vulnerable populations. This activity will include developing tools for community monitoring, orienting community representatives, and supporting them monitor. In addition, the investment will support civil society and community groups to conduct, publish and disseminate community-based research on access to HIV, TB and malaria services in at least 3 districts. The rationale for including community monitoring activities is linked to evidence which shows they can directly lead to increased service uptake. For example, in one African country, a community 113 score-carding initiative led to a 20% increase in the utilization of health services. 22 May

31 Focus of application requirement This question is required for Lower-Middle Income (LMI) and Upper-Middle Income (UMI) countries. It is not applicable for Low-Income (LI) countries. To respond, refer to guidance provided in the Instructions. For LMI countries: - - Does the funding request focus at least 50% of the budget on: disease-specific interventions for key and vulnerable populations; programs that address human rights and gender-related barriers and vulnerabilities; and/or highest impact interventions? For RSSH, does the funding request primarily focus on improving overall program outcomes for key and vulnerable populations in two or more of the diseases, and is it targeted to support scale-up, efficiency and alignment of interventions? Yes No Yes No Yes No For UMI countries: - Does the funding request focus 100% of the budget on interventions that maintain or scale-up evidence-based approaches for key and vulnerable populations, including programs that address human rights and gender-related barriers and vulnerabilities? Ensure that the funding request as described in questions 2.1 and/or 2.2 meets this focus of application requirement. 60.4% of the budget is earmarked for high impact interventions that also benefit directly key and vulnerable populations. This is illustrated in Table 4 below. Table 4: Budget for key populations, gender-related barriers and high impact interventions Module Intervention Type Prevention programs for adolescents and youth, in and out of school Comprehensive packages for AGYW, incl. cash transfers Programs that address gender-related barriers $6,634,400 3% HIV Prevention Programmes for other Vulnerable Groups Comprehensive packages Interventions for key and vulnerable populations $1,350,611 1% Treatment care and support Differentiated ART High impact interventions $95,079,649 49% Prevention programmes for general population VMMC and condoms High impact interventions $9,130,423 5% TB Care and Prevention Treatment High impact interventions $3,933,282 2% TB care and prevention Key populations (TB care and prevention) - Others Interventions for key and vulnerable populations $418, % MDR-TB Key populations (MDR-TB) - Others Interventions for key and vulnerable populations $273, % TOTAL 60.4% Amount (USD) % 22 May

32 SECTION 3: OPERATIONALIZATION AND RISK MITIGATION This section describes the planned implementation arrangements and foreseen risks for the proposed program(s). Applicants are encouraged to attach an updated Implementation Arrangements Map. To respond, refer to additional guidance provided in the Instructions. 3.1 Implementation arrangements summary Do you propose major changes from past implementation arrangements, e.g. in key implementers, flow of funds or commodities? Yes No If yes, provide an overview of the new implementation arrangements and elaborate how these changes affect the operationalization of the grant. If no, provide a summary of high-level implementation arrangements focusing only on lessons learned for the next period. In both cases, detail how representatives of women's organizations, key populations and people living with the disease(s), as applicable, will actively participate in the implementation. Include a description of procurement mechanisms. For the funding cycle, the CCM has resolved to keep the current two Principal Recipients (PRs) MoH and CHAZ. Each PR has developed guidelines that guide the selection of sub-recipients and sub-sub recipients (SSRs), in accordance with the CCM and Global Fund approved guidelines. The current institutional arrangement is shown in the diagram below. Figure 20: Proposed Implementation Arrangements for the Implementation Period Some advanced thinking on SR selection criteria and implementations arrangements for this proposed investment has been completed by CHAZ and can be seen in Annex 9. Specifically, a conceptual model for identifying non-governmental SRs has been agreed upon by the PR and the CCM. This is chiefly aimed at expanding the scope of Global Fund investment to create increased 2 space for CSOs (beyond the existing roles for FBOs). 2 These can include community-based organizations, faith-based organizations, non-government organisations (local and international), the private sector, trade unions, among others. 22 May

33 The (2017) mid-term evaluation of Zambia s current Global Fund program (Annex 6, pg. 14) indicates that increasing space for CSOs in implementation should be prioritized going forward. CHAZ will also ensure that the identification, selection and assessment focused on geographic coverage that addresses the needs of key affected populations/interest groups, extending capacity building and maximizing comparative advantage. In the case of the MoH implementation arrangement has been modified to further decentralize to district level. At Provincial level the Provincial Medical Offices will serve as sub-recipients while subsub-recipients will be at district level. This strategy is critical to timely implementation of activities at districts level. As this is a new arrangement there is need to build their capacity in all relevant functional areas (finance, programs, M&E, etc.) prior to operationalization, as well as providing regular monitoring and supportive supervision. Both the PRs have developed and have operationalized strategies and specific interventions intended for quality improvement, and improving efficiency in service delivery and resource allocation and utilization. Monitoring systems have been strengthened and sub recipients oriented on their use to ensure data quality. In service delivery supervisory visits and mentorship continue to be provided. Capacity strengthening is also supported at different levels to ensure efficiency and effectiveness. The M&E team continues to conduct data verification and audits. These quality assurance measures will not only be continued but will also be improved and strengthened during the implementation period. One challenge encountered in the previous funding cycle was that some HIV interventions were in two different departments of the ministry (HIV treatment in the department of clinical care), while most HIV prevention interventions where under the department of Public Health together with the TB programme. This at times posed challenges in coordinating implementation of some HIV/TB activities including IPT. Going forward, implementation arrangements will be fine-tuned such that individual activities are not delayed or made complicated by fragmented funding. For all PRs and SRs, the CCM is resolved to review and strengthen the grant implementation arrangement to ensure more inclusive and meaningful engagement with civil society organizations. There has been some research that has been done on key populations, and there is a number of implementing partners that are working with key pops. Most of this work, however, needs to be better coordinated through regular partner meetings to share experiences and leverage resources for a more effective response. 22 May

34 3.2 Key implementation risks Using the table below, outline key risks foreseen, including those that were provided in the Key Program Risks table shared by the Global Fund during the Country Dialogue process. You can also add key operational and implementation risks, which you identified as outstanding over the previous implementation period, and the specific mitigation measures planned to address each of these challenges/risks to ensure effective program performance in the given context. Risk Category Key Risk Mitigating actions Timeline (Functional area) Programmatic & Performance Programmatic & Performance Weaknesses in program quality across the interventions scale-up under the grants due to inadequate supervision and programme management capacity in MoH, leading to lack of compliance to protocols, follow-up of patients and workload, inconsistent implementation and low coverage of external quality assurance Not Achieving Grant Outcome & Impact Targets due to decreased domestic health financing: Budget for ARVs for 2017 was US$41M but now revised to US$18M following significant depreciation of local currency (ZMK) against US Dollar (at grant signing, FX rate was ZMK6.25 to US$1, in March 2016 it shot up to ZMK11.32, now stabilized around ZMK10.00 to US$1) coupled with fluctuating prices of copper has resulted in reduced government financial obligations to programs Health Services & Products Treatment Disruptions due to insufficient storage and distribution planning at central and peripheral levels: Storage and distribution system is operating beyond capacity using obsolete infrastructure resulting in delays in delivering medicines in facilities; inadequate forecasting and quantification: Inconsistency in forecasting and quantification resulting in demand projections being frequently adjusted. Programmatic & Performance Inadequate HMIS, Surveillance System and poor data quality,lack of full integration of some aspects in DHIS and inadequatem&e tools at level of facilities and communities: i. Weak MDRSurveillance and lack of integration of TB in DHIS; ii. Lack ofcommunity HMIS tools; iii. Inadequate Hospital HMIS; iv. Weakpatient level systems feeding into HMIS The Ministry is now focusing on mentoring and technical support supervision of district and facility staff following training. This will improve compliance to protocols, programme quality and improve consistency in implementation Ongoing The Government is still committed to increasing domestic contribution to health financing, the actual contribution in Kwacha terms has increased and continues increase. The current funding request does show in an increase in contribution with government committing to invest US$75 million over the next three years on ARV's. Ongoing Storage and distribution planning at central level will be improved with the reestablishment and strengthening of the PSM Technical working Group. MSL central warehouse is being expanded to increase its storage capacity. Four hubs are being constructed in 2017 and 19 Storage-in-a-box facilities being built in Two more hubs are planned to be constructed in Mongu and Kabombo under the new grant. The national quantification process is earmarked for support under the new grant with specific support for employment of procurement Coordinator under the MoH/MSL. Integration of TB reporting: The TB reporting system has been integrated into the DHIS. As at end of quarter 1, 2017, slightly over 60 percent of the TB diagnostic sites submitted their quarter 1 report. The program is conducting onsite mentorship in districts with low reporting rate. It is expected that the reporting rates will to go up in quarter 2, Community HMIS tools: Tools for the Community HMIS have been developed and are currently being printed. five (5) tools namely, the patient register, household register, community aggregation forms, community mobilization register and the self-assessment tools will be used to capture interventions at community level. The electronic database for the community HMIS has since been revised and attached to Health posts country wide. Inadequate Hospital HMIS: The Hospital HMIS was developed in 2016 and has been deployed to 50 Hospitals country wide. The Hospital HMIS system uses the events capture module were individual patient interactions are capture using either the OPD or IPD data entry tools. The ICD10 Codes are also embedded in this system. MoH has continued to offer on-site mentorship and TSS to build capacity in the use of this system. erratic internet connectivity in most Hospitals is the greatest threat to the full roll out of this system. Weak patient level system feeding into HMIS: The SmartCare is a system used to capture patient level data. This system is a desktop application with 22 May Dec-17 Ongoing

35 limited operability with other systems. The MoH is the process of developing an interoperability layer that will allow the SmartCare easily feed into other systems such as HMIS, elmis etc. Full roll out of this system requires massive investment ICT infrastructure and Human resources (data entry personnel) Programmatic & Performance Limited program relevance due to Inadequate coverage of interventions supporting MSM, SWs, and IDUs Programmatic & Performance Multiplicity and persistent weakness in the quality and consistency in data systems for patient tracking, commodity forecasting, and decision making - our recent review shows significant variances in patient numbers recorded at the same sites, even big sites like UTH. Programmatic & Performance Weak stock management and multiple systems for commoditymanagement. Programmatic & Performance Delay in supply chain storage and distribution strengthening Programmatic & Performance Coverage of prevention services for marginalized key population groups Programmatic & Performance Challenging legal and policy environment for implementing programs for key and vulnerable population A review of the legal and policy environment has been conducted. Through NAC a programme is being developed to address the challenges identified. Ongoing Financial & Fiduciary Low Absorption at MoH due to new implementation arrangements: At grant signing, Ministry of Community Development and Mother Child Health (MCDMCH) was supposed to be SR for MOH grants. However, shortly after grant signing, MCDMCH was dissolved and it took some time for MOH to receive clearance from Cabinet to engage the Provinces and districts directly and this was only done at the beginning of 2016 The implementation and absorption has since improved. The SR's are now Provincial Health Offices and some Parastatal organisations. In the new Funding request the districts will be sub-sub recipients in order to further improve absorption. Ongoing Financial & Fiduciary Fraud, corruption, theft of funds contributed by historical incidence and period of PR transitional arrangement Financial & Fiduciary Large outstanding debt for historic ARV purchases Financial & Fiduciary Unstable trading between Kwacha and the US dollar, affecting purchasing power and historic co-financing commitments The interventions for MSM, SW's and IDU's are being implemented through National AIDS Council and the current funding request builds on this programme The concerns on weakness in the quality and consistency in data systems for patient tracking (SmartCare) have been noted and the MoH has requested an agency (BroadReach) to develop an upgrade. It is expected that once the upgrade is developed and rolled out most of these discrepancies noted in reports from SmartCare will be resolved. The Ministry of Health is focused on developing one commodity management system elmis. There will also be Hub based redistribution of products from overstocked to under-stocked health facilities. End User Verification exercises and supervision will be conducted. MSL is also developing an Integrated Inventory Management System The delays have now been resolved. Construction of the four hubs and nine storage-in--box facilities under the current Global Fund grants are set to start in June/July The tendering for the three hubs has been completed. Support includes the procurement of motor vehicles for the hubs under the current grant and will be supported from both MoH and USG. The Current MoH NFM grant is supporting the coordination of services for marginalised populations as well as developing the capacities of marginalized populations organizations. The grant also provides for integrated service provision of the marginalised populations in specific sites Establishment of strengthened PMU with detailed SOPs. Strict adherence to Accounting principles, standard terms and conditions Training/orientation in risk management for MoH and PMU staff The Ministry of Health has been dismantling this debt. The plan is to continue and complete this by July Fiscal space for has been created by using current GF grant savings to fill the ARV existing gap Fiscalization of National expenditure; Stabilization of the exchange and interest rates 22 May Ongoing Ongoing Ongoing Dec-17 Ongoing Ongoing Ongoing Ongoing

36 SECTION 4: FUNDING LANDSCAPE, CO-FINANCING AND SUSTAINABILITY This section details trends in overall health financing, government commitments to co-financing, and key plans for sustainability. Refer to the Funding Landscape Table(s) and supporting documents as applicable. To respond, refer to additional guidance provided in the Instructions. 4.1 Funding Landscape and Co-financing a) Are there any current and/or planned actions or reforms to increase domestic resources for health as well as to enable greater efficiency and effectiveness of health spending? If yes, provide details below. Yes No b) Is this current application requesting Global Fund support for developing a health financing strategy and/or implementing healthfinancing reforms? If yes, provide a brief description below. Yes No c) Have previous government commitments for the allocation been realized? If not, provide reasons below. Yes No d) Do current co-financing commitments for the allocation meet minimum requirements to fully access the co-financing incentive, as set forth in the Sustainability, Transition and Co-financing Policy? If not, provide reasons below. Yes No e) Does this application request Global Fund support for the institutionalization of expenditure tracking mechanisms such as National Health Accounts? If yes or no, specify below how realization of co-financing commitments will be tracked and reported. Yes No Current and Planned Actions to Increase Domestic Health Funding and Funding Efficiencies From 2014, the Government of Zambia has maintained a steady allocation towards drugs for HIV and TB, and has continued to fulfil its commitment to provide support for health personnel emoluments and other health programs. Table 5 below illustrates the government of Zambia s budget commitments for select drugs and human resources expenses that are relevant to this funding request. In addition, government investments in major program areas which are not reflected in Table 6 include human resources, service delivery, and infrastructure development and maintenance. Table 5: Zambian Government Budget for HIV/TB Drug/Salaries for (ZMW Millions) Program PEs Other emoluments ARV TB Drugs Malaria Drugs Other Drugs Other programs TOTAL ,086 2, , ,758 2, ,110 4,540 3, ,702 5, Projection 2019 Projection 2020 Projection 4, ,907 6,770 4, ,112 7,811 5, ,317 8,850 Although this increase in domestic funding for HIV and TB is commendable, it is important to note that since 2015, Zambia has been facing a challenging economic climate. Falling copper prices, pressure on the government s operating and investment budget and electricity-supply shortages are affecting the real economy. In spite of this, the Government of Zambia has continued to increase health spending. However, in United States Dollar terms, this increase is less visible; the Zambian Kwacha (ZMW) depreciated by 42% against the United States dollar (USD), raising end-of-year inflation in that year to 21%. 22 May

37 In the context of this economic downturn, initiatives to increase domestic funding for health are being implemented. The Government has launched an economic recovery program (in the second half of 2016), under the social sector theme Leaving No One Behind. This plan includes a modest increase of 0.6% in the health sector budget, from 8.3% to 8.9% of the total national budget. Compared to the overall allocation to the entire social sector, the health allocation represented a substantial share of 28%, second only to education with the lion s share of 51%. Zambia s National Development Plan Vision includes a key target to increase annual health expenditure per capita to a period average of US$150, comparable to other middle income economies like Botswana and South 115 Africa. In addition, the Government has embarked on a policy of recruitment and deployment of a cadre of Community Health Workers (CHWs), who are expected to contribute greatly to health outcomes in the country s HIV, TB and malaria programs. The stated objective of the Government is to improve universal health coverage for all, and therefore the greater part of the health sector budget expenditure addresses investments in infrastructure, preventive health, medicines and human resource. The government has also invested ZMW6.3 million towards the establishment of the National Social Health Insurance Scheme, which is aimed at providing sustainable funding for essential healthcare in the long run. Furthermore, a policy to recruit and deploy front line human resources is underway, and Government has pledged to sustain this for the foreseeable future. A health financing strategy will be developed and the drafting of the Social Health Insurance Bill is well advanced; the Bill is expected to be presented to Cabinet for approval and then tabled in Parliament in Social Health Insurance is expected to augment resources available for Health spending. Other ongoing initiatives to achieve sustainability of Global Fund-financed programs include improving resource allocation and strengthening governance. In spite of these efforts, the Government still requires and recognizes the critical contributions made by development partners who continue to fund a significant portion of the country HIV and TB responses. For example, modelling shows that in the Abuja target scenario (where the government allocates at least 15% of its annual budget to health), Zambia will only be able to cover 13.6% of its total HIV resource needs. Even in a maximum effort scenario, Zambia will only be able to cover about 116 half (50.9%) of its total HIV resources needs with domestic funding. This underscores the fact that while there is a need to increase domestic spending, continued partner investments remain crucial. Realization of Government Commitments for and Requirements for Zambia committed to spending $ on its HIV program and $18.00 million on its TB program over the funding cycle (the implementation period). The Government of Zambia has met these commitments. In order to access its full allocation, Zambia must commit at least $39,507,900 in additional co-financing over funding cycle. These co-financing commitments will be met and exceeded, according to budget projections. Refer to the attached Funding Landscape Table for the specific amounts of Zambia s historic and projected domestic commitments. Note: A letter to confirm historic and projected domestic financing is available upon request. Institutionalization of Improved Expenditure Tracking Mechanisms This funding request includes the roll-out of expenditure tracking mechanisms (Navision and REMS) which will be applied not only to HIV and TB programs but also across the broader health sector, and will enhance financial management and oversight. Further the government regularly reviews funding availability for key health programs in order to mobilize resources, as appropriate. Recall that two of the key gaps identified in the mid-term evaluation of Zambia s current Global Fund program (Annex 4) include the absence of a reliable system to actively track counterpart financing commitments and the fact that there is no sustainability plan to address specifically for the Global Fund investments. In light of this identified need to develop a sustainability plan/ roadmap through a multi-sectoral approach, efforts will be made to pursue this objective over the coming funding cycle. 22 May

38 4.2 Sustainability Describe below how the government will increasingly take up health program costs, and actions to improve sustainability of Global Fund financed programs. Specifically, a) Explain the costs, availability of funds and the funding gap for major program areas. Specify in particular how the government will increasingly take up key costs of national disease plans and/or support health systems; including scaling up investments in programs for key and vulnerable population, removal of human rights and gender-related barriers and enabling environment interventions. b) Describe actions to improve sustainability of Global Fund financed programs. Specifically, highlight key sustainability challenges of the program(s) covered by the funding request, and any current and/or planned actions to address them. Costs, Availability of Funds and Funding Gaps for Major Program Areas The total cost of Zambia s HIV program is estimated (through models) to reach $486.7 million by 2020, up from $400.7 million in 2017 (Figure 21). The bulk (56.3%) of the anticipated resources over the five years will be required for treatment and care, as the test-and-start policy is rolled-out and the targets are achieved. The prevention interventions together will take up 28.7%. Importantly, in the longer-term projections, the costs will eventually begin to plateau around 2025, due to the impact of both the prevention efforts as well as the preventative effect of treatment scale-up through test-and-start. Figure 21: Estimated Resources Required for the NASF Interventions (US$ million, prices) 22 May

39 Figure 22: Estimated Funding Gap for the NASF (US$ millions, ) 119 In 2015, The Global Fund invested $25,854,905 in Zambia s HIV program, and PEPFAR invested 120 $ In 2012, $263,305,968 of Zambia s HIV funding was international and $15,829, was domestic public. By 2018, domestic funding for HIV in Zambia is projected to grow to $ million. Despite these investments, the national multi-sectoral HIV response has an estimated financial gap of $ million across the implementation period (Figure 22). In 2018, the financial gap is estimated at $ million, which increases to $ million in 2019 and $ million in When the financial gap is analyzed against specific program areas, the largest financial gaps are around treatment (ART), TB/HIV collaborative activities and VMMC. Spending on HIV programmes is heavily supported by the United States Government (USG). Funding for the PEPFAR Country Operational Plan for 2018 (COP 2017) has been approved at $403.9 million. Estimates for 2019 and 2020 are anticipated to decrease by 10% annually. Funding from other Partners is currently unknown, and also estimated to decrease by the same margin year-on-year based on 2017 figures. For Zambia s TB program, the proportion of TB funding from domestic resources was 29%, with 63% 123 coming from international funders in The reliability of TB funding fluctuates quite dramatically year on year (Figure 23), making effective longer-term planning for the response an especially challenging endeavour. Figure 23: Zambia s Total TB Budget (US$ millions) 124 The (draft) TB NSP ( ) (Annex 2) has been fully costed and the total resource needs for the implementation period amount to $90,895,163. The financial gap is estimated at approximately US$86.7 million, with major funding gaps in TB treatment and care and TB/HIV. Recent changes in the funding landscape help close this gap slightly. In March 2017, Zambia launched a $45 million five-year TB project funded by the World Bank, aimed at fighting TB in mining towns. 22 May