Note: this posting has been revised from the previous version.
An analysis developed with the aid of the USAID-funded Deliver Project shows that Zambia is facing a massive gap in the financing required to reach country targets for expanded access to antiretroviral therapy (ART).
The gap goes from $8.2 million for 2011 to a whopping $57.6 million in 2015. The Deliver Project supports the national group chaired by the Ministry of Health to revise these estimates on a quarterly basis, and the latest can be downloaded here.
The gap could sabotage plans for scale up of life-saving treatment. The country aims to increase the overall number of patients receiving ART by about 24 percent from 2010 to 2015. This scale up would include about a 40 percent expansion in the number of mothers and babies receiving prevention of mother-to-child transmission (PMTCT) from 2010 to 2015.
The Deliver Project, run by USAID contractor John Snow, Inc. (JSI), has been deeply engaged in helping Zambia improve its capacity to forecast resources and plan procurement. Walter Proper, the country director for JSI, told our congressional delegation he was concerned about the gap. He said achievement of cost efficiencies in the delivery of treatment will not be adequate to bridge the gap. Due to lack of service capacity, enrollment of new patients for ART has stopped in some locations.
Prospects for U.S. support for scale up are unclear. The initial draft of the President’s Emergency Plan for AIDS Relief (PEPFAR) Partnership Framework for Zambia, now being finalized, said the U.S. government would “endeavor” to expand ART coverage “as available resources may allow.” The gap analysis assumes that the U.S. government support for ART expansion will increase to $30 million in FY 2011 and then fall flat to $27 million for each of the remaining years. However, it is expected that the US will be providing soon some additional resources specifically for PMTCT scaleup.
The gap is also aggravated by elimination of support for ART from UNITAID, which is shifting support to malaria, plus the conclusion of grants made several years ago by the Global Fund to Fight AIDS, TB and Malaria.
Civil society activists in Zambia are closely tracking any stockouts that develop, and they have included in their demands a call on their own government explore creative options to help close this gap. The gap analysis shows that the government is proposing some increase in its contribution, from $5.1 million in 2010 to $7.5 million in 2015. Its contribution has been affected by the economic recession, which led to budget cuts for all government programs, plus the recent devaluation of the Zambian currency, the Kwacha, affected the value of its contribution. Yet, even if the government doubled its contribution, the gap would still be enormous, especially beginning in 2012.
The gap could be alleviated by a successful application to the Global Fund for new resources. Last week Zambia submitted a Round 10 application to the Global Fund, mainly for resources for ART, with the United Nations Development Programme as the principal recipient.
Carol Nyirenda, who met with our congressional study tour in Zambia last week and who is also the communities delegate on the Board of the Fund, said it is a high quality proposal that asks for a modest amount of funding to support ART scale-up. Michael Gwaba, also of the Community Initiative for Tuberculosis, HIV/AIDS and Malaria (CITAM+), said that he “hates to think of what would happen” should this proposal not go through, since that would stall expansion of life-saving treatment.
There is considerable anxiety among some in civil society about whether factors unrelated to the substance of the proposal, such as the recent corruption scandal involving some employees at the Ministry of Health, might hurt the prospects for approval, despite the fact the funds would not be channeled through the Ministry of Health.
Poor communication with the Fund also seems to pose a risk — PEPFAR was harshly critical of the Fund bureaucracy in its Zambia COP Report 2010, stating that there is “substantial opportunity for miscommunication” over issues surrounding grant signature (on page 7 of the Report).
The fact that the Round 10 resources would be channeled via UNDP, while there seems no alternative in this case, also raises some concerns. The Fund recently documented deficiencies in financial management by the UNDP in Congo DRC, and the Fund has been critical of UNDP’s lack of transparency and creation of parallel systems. Plus UNDP would charge a 7 percent management fee, plus fees charged by its procurement agent UNICEF, and that would seem to take funds away from services.
Dr. Jeff Stringer, Director and CEO of CIDRZ, one of Zambia’s biggest recipients of PEPFAR funding, told our congressional delegation that “while there are cost efficiencies that can help, this is not the time to make us slow down” in the response to AIDS, including ART. “We are almost at the tipping point for Zambia to be able to get a handle on this problem.”
Stringer said that slowing down the expansion of access to ART also means a missed prevention opportunity, since patients receiving ART are less likely to transmit HIV. Stringer and his colleagues also warned that a slowdown in resources for ART could reduce flexibility to try new approaches and compromise not only the expansion to new patients but also the quality and consistency of the care that existing patients are receiving.