THE PROBLEM

Angola, a lower-middle income country of 35 million people located along the west coast of Southern Africa, has high burdens of disease for HIV, TB, and malaria. Efforts towards epidemic control have progressed gradually under challenging and complex conditions; key administrative, financial, and social institutions were greatly weakened by a decades-long civil war from which the nation is still recovering, and the recent economic difficulties have reduced health budgets and decreased stability for already-vulnerable populations.

Throughout the second half of the 2010s, the Government of Angola (GoA) consistently struggled to collect, analyze, and report accurate data reflecting quantification, budgeting, and spending on its HIV, TB, and malaria programs. As a result, documentation and assessment of performance against co-financing commitments made to the Global Fund was weak to nonexistent. Systemic gaps in health financing institutions and processes posed a serious risk for Angola not only of failing to meet Global Fund commitment and requirements, but also of losing ground in the fight against the three diseases due to inadequate program coordination and resourcing.

Following a 2019 visit by the Office of the Inspector General (OIG), the Global Fund formally requested that the Angolan Ministry of Health (MoH) amend these gaps, setting clear and detailed demonstration of commitment compliance as a prerequisite for accessing funding during the 2020-2022 grant allocation period.

THE PHAROS SOLUTION

Pharos was asked by the Global Fund to provide technical and capacity-building support on health financing for the GoA and MoH, with a focus on enabling effective formulation, tracking, and reporting of co-financing commitments. The project began in 2020 with two main phases, but as initial objectives were successfully completed and more ambitious ones emerged, the Global Fund renewed Pharos’ assistance multiple times, resulting in a sustained and productive partnership yielding results across several years and a total of five work phases.

Phase I: In the first phase of the project, the Pharos team assisted in the creation of a Technical Working Group (TWG) composed of technically knowledgeable MoH staff from the HIV, TB, and malaria programs as well as other key stakeholders. Despite travel restrictions imposed by the COVID-19 pandemic, we successfully constituted the TWG and developed a Standard Operating Procedure (SOP) defining a new methodology for collecting and reporting performance data against general and specific commitments made as part of Global Fund grant agreements. Then, we helped the TWG apply the SOP to collect and report on actual co-financing commitments for the HIV and malaria programs for the 2017-2019 grant period. As a direct result of these enhancements to the GoA’s ability to demonstrate compliance with Global Fund commitments, the Global Fund issued a new Grant Allocation Letter to Angola for the 2020-2022 period.

Phase II: In the second phase, Pharos revised the SOP and co-financing report based on feedback from OIG and Global Fund, and helped the TWG apply the improvised SOP to the TB program for the 2017-2019 grant period. Then, we worked with national specialists to draft a co-financing commitment letter for NFM3/GC6 that was approved and signed by all parties. Once that was accomplished, the Pharos team developed a new version of the SOP tailored to enable monitoring of the new commitments, built monitoring and reporting capacity at the Ministry of Health through targeted trainings and development of reporting tools, and developed a roadmap of recommended actions for the long-term sustainability of co-financing reporting in Angola.

Following the successful completion of Phases I and II, Pharos’ assistance to GoA and Global Fund was renewed for three additional project phases. Across all additional phases, we worked to: (1) provide technical assistance on co-financing monitoring, track, and reporting, including through direct technical work driving the development of comprehensive co-financing reports for all three diseases submitted in 2021, 2022, and 2023, and (2) strengthen the organization, capacity, and coordination of key health financing teams and personnel operating in Angola, including through virtual and in-person workshops and trainings, the development of additional guidelines and informational materials, and the facilitation of peer-to-peer learning.

Phase III: Beyond the activities listed above, Pharos worked during the third phase to build and consolidate the systems for HIV, TB, and malaria expenditure tracking, focusing on commodities and the specific areas prioritized in the NFM3/GC6 commitments, and to evaluate the utility of the SOP.

Phase IV: In the fourth phase, carried out during 2022, Pharos focused on identifying human resources-related gaps in health financing flows for the three diseases programs, strengthened linkages between key health financing processes including quantification, procurement planning, budgeting, and expenditures, developed monitoring plans for each of the draft commitments proposed by GoA for the GC7 grant period, and improved various key documents including the SOP and ToRs.

A few of Pharos’ numerous deliverables, including capacity-building materials and technical reports are included below for reference. Though deliverables and focus areas have varied from phase to phase, the primary outcome of all phases has been to help GoA to strengthen financing institutions, capacity, and processes for the three diseases and for the health sector more broadly.

LOOKING AHEAD

Despite facing major limitations initially, Angola has proven to be the best and perhaps only example of a country accounting for each dollar of Global Fund co-financing commitments for the NFM2 and NFM3/GC6 grants. This project has become an exemplary model in the Global Fund’s portfolio of how challenges in tracking co-financing commitments can be overcome, and of the sustainability and transition successes that can be realized by countries when the production and efficacious use of high-quality co-financing data is prioritized and supported.

Status: Completed, May 2020 – December 2023

Team Members Involved: Robert Hecht, Gabriela Cohen, Ana Diaz, Diana Gonzalez, Nathan Isaacs, and Mila Dorji

For more information, contact Mila Dorji at [email protected].