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PROGRAM SCORECARD

Nigeria

Malaria

July 2, 2013

1. RENEWAL RECOMMENDATION SUMMARY

Grant

number PR name

Performance

Rating

Recommendation

Category*

Recommended

Incremental

Amount

% of Adjusted

Interim

Funding

Amount**

% saving

Within

Investment

Range?*

NGA-

809-

G11-M

Society for

Family

Health

(SFH)

A2 N/A 73,671,805 N/A N/A N/A

NGA-

809-

G14-M

National

Malaria

Control

Program

(NMCP)

B2 N/A 93,328,195 N/A N/A N/A

Total Interim Funding Amount (all PRs) in US$ 167,000,000

Total Recommended Incremental Amount (all PRs) in US$ 167,000,000

100% 0% N/A

*Does not apply to interim funding applications. **Refers to the amount that has been allocated to the Nigeria malaria disease program through the interim funding model.

Background: This application and program scorecard refers to interim or “top-up” funding for the existing Round 8 malaria grants under the private sector Principal Recipient (PR) Society for Family Health (SFH) and the public sector PR National Malaria Control Program (NMCP). These grants went through Phase 2 renewal in May 2012 and signed their Phase 2 agreements in August 2012 for an incremental US$ 148 million arriving at a total Phase 1 and Phase 2 commitment of US$ 343 million over 2009-2015. In line with the National Malaria Strategic Plan (NMSP) 2009-2013, the Global Fund grants support interventions in 30 out of the 36+1 states of Nigeria contributing to : • Reach universal coverage of long-lasting insecticidal nets (LLINs) through mass campaigns and routine

distribution • Increase ACT roll-out in the public and private sector; • Increase malaria diagnosis using microscopy at referral centers and rollout of RDTs at primary health

facilities; In 2009, the NMCP with support from key RBM partners launched an ambitious initiative to scale up for impact increasing access to and use of LLINs through state-wide mass distribution campaigns. The country adopted a mixed model, comprising of ‘catch-up’ (through mass universal coverage campaigns) and ‘keep-up’ (through routine/continuous distribution) phases as described in the NMSP 2009-2013. The Global Fund funded the distribution of 30 million LLINs through mass campaigns in Phase 1 of the Round 8 grant and allocated funding for distribution of 17 million LLINs through both routine distribution (12.4 million LLINs) in Phase 2 in 30 states, while also contributing to the finalization of LLIN campaigns in Delta, Osun, Sokoto and Ogun states in 2013 (4.6 million LLINs).

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In April 2013, the Global Fund announced an additional US$ 167 million of interim malaria funding allocated under the New Funding Model (NFM) to Nigeria for 2013-2014, calculated as US$ 151m to replace 26 million

LLINs previously financed by the Global Fund in 2009 and 2010 in need of replacement and US$ 16m, because the country has received less funding than it would have under the NFM allocation principle for 2013-2014. In accordance with the above allocation, the Country Coordinating Mechanism (CCM) submitted a request of US$ 153 million to replace LLINs through mass campaigns and US$ 14 million for the procurement of ACTs and RDTs, which are largely underfunded for the period 2013 -14. This investment is to complement the existing program and funding under the Phase 2 malaria grants and will feed into the already established program structures and grant management efforts of the Round 8 grants. The Nigeria malaria program has also been identified as eligible for Global Fund Standard Application in 2014 under the NFM full roll out. The CCM will be encouraged in that application process to review their current strategies in light of new evidence, taking into account the new NMSP for 2014-2018 (currently under development and expected to be finalized in October 2014) with the possibility to include interventions not covered by the existing malaria grants. It is expected that Nigeria will work on the malaria concept note /Standard Application in the first quarter of 2014, leading to signature of a new funding agreement by the end of second quarter of 2014 earliest.

2: EPIDEMIOLOGICAL CONTEXT AND PROGRAM PERFORMANCE

2.1: Epidemiological Situation and Country Context Brief overview of the current and evolving epidemiological context, with clear explanations for major trends.

Please briefly summarize the key elements from Country Dialogue as relevant for the portfolio. Please also

describe key partners and their role in supporting the program implementation.

Epidemiological situation

Malaria is endemic in Nigeria with 100% of its population (more than 160 million people) at risk of infection and 97% living in high transmission areas.

Nigeria carries 31% of the global malaria mortality burden as per the WHO World Malaria Report 2012 and thus ranks 1

st in the world on absolute number of malaria deaths.

According to national estimates on cause-specific mortality, malaria in Nigeria accounted for 11% of maternal mortality, 25% of infant mortality and 30% of under-5 mortality (Malaria Program Review (MPR) 2012). The WHO estimates show that 207,000 deaths a year in Nigeria are attributed to malaria (WHO, World Malaria Report 2012)

Nigeria contributes to one-fifth of global malaria cases and malaria case incidence remains high, with some fluctuations in reported cases over the last years. The national Malaria Program Review (MPR) conducted in 2012 concluded that data limitations would not allow drawing a valid conclusion as to whether the malaria incidence is increasing or decreasing; only that it remains high. Data from a rapid impact assessment of health facilities conducted in 2011 show a 22% reduction in slide positivity rate among suspected malaria cases, indicating a possible decline in malaria among fever cases. Despite these encouraging findings, malaria case incidence remains high.

The 2010 NMIS reports an average parasite prevalence of 42% in children under-5 years old. Rural areas (48%) shoulder twice the burden of urban areas (23%). However, absence of prior population-based national surveys that measured parasite prevalence makes assessment of epidemiological trends difficult (please see further details on this and other trends under the impact section).

Nigeria’s progress towards meeting the MDG target to reduce case rate by 75% between 2000 and 2015 is slow (at 36% of target). Malaria mortality has been reduced by 25% while the goal for 2015 is a 50% reduction.

Policy considerations

An estimated 60% of Nigerians use the private sector as the first point of contact when seeking health care. This is estimated to be even higher for those seeking malaria treatment, but private sector regulation and enforcement is weak.

Nigeria has been one of the six AMFm pilot countries. During Phase 1, outlets with available quality assured ACTs increased from 28% to 54%. Due to absence of a private sector case management strategy, ACTs were administered without the use of diagnostic testing. A private sector case management strategy is currently being elaborated by the NMCP, as recommended by the MPR of

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2012, with the support of key partners and will be integrated in the NMSP 2014-2018.

The PR SFH recently finalized a study to determine if small private sector vendors and pharmacies, Patent Proprietary Medicine Vendors (PPMVs) can do RDT testing safely. The study has had positive results and this intervention has also been recommended as per the MPR 2012. The PRs are currently making efforts towards changing the national policy to allow PPMVs to handle blood samples; at present such practice is prohibited. The above efforts shall inform future funding applications under NFM as it is critical to strengthen this component overall.In Nigeria, IRS implementation is focal, i.e. targeted at communities with high malaria burden. Currently two Local Government Areas (LGAs) in two of states identified for interim funding have been targeted for IRS activities. In those states, IRS and LLIN interventions are using synthetic pyrethroids. This practice will need to be changed in line with WHO guidance to minimize selection for pyrethroid resistance. Nigeria is making plans for insecticide resistance surveillance and management to ensure efficacy for insecticide use for vector control in the country. Sentinel sites are being established across the country to implement this activity.

Reports of studies on insecticides resistance in the country are currently being compiled in order to establish a national database. This is part of the development of an insecticide resistance surveillance and management system. In addition, Nigeria is developing guidelines for insecticide resistance mapping and surveillance. These guidelines are also being finalized.

The NMCP has adopted integrated community case management (IMCI) to address diagnosis and treatment of febrile illness at the periphery of the health system and is coordinating with the Family Health Department and National Primary Health Development Agency to start implementation in two states to gather operational data to inform further roll out. Guidelines on the implementation of IMCI in Nigeria have been developed. The NMCP will provide ACTs and RDTs in addition to capacity building support while ORS, zink and antibiotics are provided by the Family Health Department.

Partnership environment for malaria

Roll Back Malaria (RBM) partners are well represented in Nigeria and provide support to the NMCP through technical and policy working groups under national leadership contributing to harmonization of activities and and enhancing aid effectiveness.

The US President’s Malaria Initiative (PMI) is the second largest funder for malaria control after the Global Fund and finances malaria control interventions in nine states. Collaboration focuses on supply chain management and M&E, e.g. national HMIS-DHIS strengthening and roll-out.

The World Bank finances all malaria actvities in seven states through the NMCP. Collaboration focuses on institutional development and M&E.

DFID supports malaria activities in eight states. Collaboration focuses on private sector case management, AMFm and institutional development.

Besides technical advise and policy development, WHO has regional NPOs in six zones, funded under the Global Fund grants, who support activities at regional and state level.

Secretariat guidance to the CCM on interim funding request In April 2013, the Global Fund announced the additional US$ 167 million of interim malaria funding allocated under the NFM to Nigeria. This was communicated to CCM and stakeholders during a country visit and steps for preparation of the interim funding request were discussed. Follow-up in country meetings followed to further explain how the interim funding amount was calculated and what would be the expectations around the country dialogue and submission. It was also explained that due to long LLIN delivery times it would be important to stick to the timelines for submission and grant making to allow orders for LLINS to be processed as soon as possible. The interim funding request was developed under the guidance of the CCM, with the involvement of the NMCP, SFH, partners and stakeholders. An RBM funded consultant supported the country dialogue and concept note development.

2.2: Program Performance and Impact This section describes the impact that the Global Fund support is having in a country, collectively with investments of government and other partners, presenting a full picture of progress against effective coverage and impact needed to end / eliminate/change the course of the epidemic in the country. This section should (1) summarize grant programmatic and financial performance, (2) key partners and their role in supporting programs and (3) relevant operational and capacity issues.

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Progress towards impact

Coverage

LLIN coverage and use: The proportion of households owning one or more insecticide-treated nets (ITNs) increased from only 8% in the 2008 DHS to 73% as reported in the 2012 MPR. The proportion of children under five reported to have slept under an ITN the night before the survey increased from 6% in the 2008 DHS to 29% in the 2010 MIS. Net ownership and use have varied by state, but remain significantly below national and global targets. Low utilization rates can be linked to absence of BCC activities in the post-campaign period focused on net hang-up and use. Post-campaign activities aimed at increasing net usage are part of the planned activities in this application.

Treatment and IPT: The proportion of children with fever who were treated with antimalarial medicines increased from 33% in 2008 to 49% in 2010, but only 6% took ACT in 2010. Contributing factors to the poor uptake of ACTs include frequent stock outs in public sector health facilities; and the high cost of ACTs in the private sector. As per the World Malaria Report of 2012, the ACT coverage in 2011 was only 17%. The percentage of pregnant women that receive at least two doses of IPT has remained low across the years with marginal increase from 6.5% in 2008 to 13.2% in 2010. This is linked to low attendance at antenatal care clinics, negative perceptions of IPT and poor health worker training.

Impact

Surveys including the 2010 NMIS and 2011 MICS/Millennium Development Goals (MDG) Indicators report (MDGIS) indicate that slow progress is being made towards the achievement of the MDGs and NMSP goals.

All-cause under-five mortality has shown a 40% reduction between 1990 and 2010, and a 30% decline between 2000 and 2010.

Recent data triangulation was undertaken by the NMCP and Oxford University to examine the epidemiology of malaria in Nigeria and assess changes in the prevalence of Plasmodium falciparum over time. This analysis indicated a considerable reduction in the endemic areas. It also indicates that between 2000-2010 all states may have witnessed a reduction in transmission intensity.

Reported malaria deaths started to decline since 2007, reflecting the potential effect of increasing ITN coverage and case management. However, irregularities in reporting from many states in various years make proper assessment of such observed trends difficult.

Overall, the malaria program in Nigeria has so far demonstrated limited progress towards impact. However, current rapid scale-up of LLINs coupled with the planned scale-up of diagnostic testing and treatment are likely to change the trajectory towards the RBM/MDG and national strategic targets. There are early signs of decline in test-positivity, reported health-facility deaths and all-cause under-five mortality. Recent systematic analysis of multiple small-scale sub-national surveys also highlighted a possible decline in malaria burden over the last decade.

A Malaria Program Review (MPR) was conducted in October 2012. The PRs and partners are currently working together to ensure the MPR recommendations are addressed and incorporated into program implementation. The most recent update highlighted the following: 1) HMIS forms are being printed and will be disseminated soon as a step in operationalizing the routine malaria surveillance system; 2) NMCP is establishing additional sentinel surveillance sites for parasite-based epidemiological monitoring of case incidence and mortality trends, as well as vector surveillance and insecticide-resistance; 3) NMCP is conducting training to build analytical capacity at states and LGA levels to improve reporting & data quality; 4) NMCP currently developing guides and SOPs regarding replacement of ITNs including through routine distribution channels, to feed into ITN distribution tracking and attaining/monitoring progress towards universal coverage.

Surveys and data gaps

The coverage of malaria interventions in Nigeria was measured during the NMIS in 2010 and the MICS in 2011. NMIS 2010 also generated baseline parasite and anaemia prevalence estimates for future assessment of progress and impact. The 2012 national MPR recommends that Nigeria initiates efforts to generate evidence to update its malaria epidemiological profile. The next impact surveys are planned for 2013 (National Demographic and Health Survey), 2014 (Malaria Indicator Survey), and 2015 (Multiple Indicator Cluster Surveys), co-funded by the Global Fund grants.

The MPR, which was planned and conducted with Global Fund participation has been instructive in identifying program bottlenecks and priorities and progress has been made in addressing of the recommendations.

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The new National Malaria Control Plan for 2014-2018 is currently under development and is expected to be finalized by October 2014. The plan, which will inform future strides in investment, will include a private sector case management strategy.

Program performance Both Round 8 malaria grants were affected by a late start of activities in Phase 1 due to delays with the AMFm process, late fulfillment of Conditions Precedent related to Procurement and Supply Management (PSM) and an OIG country audit and investigation in 2010-2011 which led to the removal of one of the three PRs. This affected disbursements and procurement, leading to an erratic delivery of ACTs and RDTs, affecting in particular the performance of treatment and diagnosis-related indicators. In Phase 2, NMCP took over the 18 States managed by former PR YGC. In general, the supply of malaria commodities in Nigeria is far outstripped by the demand, while reporting structures are still not robust enough to correctly reflect the results achieved. The LMIS system has been established and workers trained, but the actual operationalization of the system has been limited as the pipelines are not sufficiently filled. Low grant performance on ACTs has also contributed to the overall low coverage at national level. Progress on diagnosis has been limited, due to limited availability of RDTs and low awareness and persistent negative perceptions regarding the accuracy of the tests.

SFH For the PR SFH, which focuses on private sector channels, performance as of December 2012 against core indicators is as follows:

LLINs – 3,153,609 out of a target of 3,390,609 LLINs were distributed to the end-user;

ACT treatment for <5 through private health sector – 616,151 out of 848,935;

ACT treatment for >5 through private health sector – 1,204,996 out of 1,251,462;

RDT use in private health facilities reported at <1%. Performance has greatly picked up following the availability of commodities. This has been especially visible in the last half of 2012 where the PR was rated A2, their first time to achieve this rating since the beginning of 2010.

NMCP

For NMCP performance as of December 2012 against core indicators is as follows:

LLINs – 4,158,990 out of a target of 4,925,778 LLINs were distributed to the end-user;

ACT treatment for <5 in public and private health sectors – 1,391,653 out of 5,715,729;

ACT treatment for >5 in public and private health sectors – 1,621,605 out of 5,418,077;

RDT use in public and private health facilities reported at 11%.

Latest performance rating is B2, with core indicators tracking treatment and parasiotological testing below

acceptable levels; 24% <5 and 30% >5 treatment and 11% for RDTs. LLIN distribution on the other hand

returned promising results with 84% performance. The poor performance of the PR in the last half of 2012

has been mostly due to the transition between Phase 1 and 2 with delays in PR signing of Phase 2

agreements with their SRs. This refers in particular to the 12 state SRs, which have come on board in

Phase 2 and whose capacity required to be assessed and the states taken over by the NMCP from YGC

where activities started with a delay.

Financial performance

SFH:

The Global Fund has disbursed a total amount of US$ 129,820,218 to SFH as at 31 December 2012, representing 95% of the PR’s Round 8 budget up to the cut off date. As at May 2013, the Global Fund had disbursed US$ 133,840,533 representing 82% of the total Round 8 grant.

The PR absorbed 73% of the cumulative budget as at 31 December 2012, while it absorbed 77% of funds disbursed by the Global Fund at the same date.

The PR has generally performed well in the financial management of the grant. The PR continues to make good progress against issues such as external audit process and recommendations, challenges with monitoring of assets/inventory and tracking of budget expenditures.

NMCP:

The Global Fund has disbursed a total amount of US$ 151,272,729 to the PR as at 31 December 2012. This represents 94% of the PR’s Round 8 budget up to the cut off date (31 December 2012). As at May 2013, the Global Fund had disbursed US$160,340,463 representing 89% of the total Round 8 grant.

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About 76% of the disbursement was made directly to VPP for procurement of LLINs, ACTs and RDTs on behalf of the PR.

The PR experienced significant issues in relation to the financial management of the grant including: accounting and use of accounting software, quarterly and annual reporting, external and internal audits, and SR financial management & oversight, but has made progress in strengthening its Financial Management Systems capacity, with particular focus on the financial control environment.

The NMCP financial management system has in the first half of 2013 undergone a number of reviews and restructuring with the objective of having a robust financial management system. There are still challenges especially in areas of staff capacity and competence and consistent adherence to procedures and application of controls. It is expected that the planned recruitment of a qualified accountant to head the finance unit and one additional staff to support the internal audit unit will help to strengthen the controls in NMCP.

The new National Coordinator has demonstrated strong commitment and leadership to address the recommendations and requirements made by the Global Fund, resulting from ongoing reviews to date. She is at the forefront of implementing the necessary changes in the Global Fund project unit. NMCP’s financial statement for the year ended 31 December 2012 is currently being audited.

A special LFA review to further assess the control environment at the PR is almost finalised. Report findings and recommendations will be part of the PRs capacity building plan.

Both PRs have been subject to the 2011 OIG Country Audit and subsequent investigation. To date a draft investigation report has been shared by the OIG with the PRs and CCM and both PRs have acknowledged the need to follow-up on the findings and make the necessary repayments. Cross cutting challenges identified during Phase 2 renewal and in the Malaria Program Review (MPR) of 2012 are listed below, linked to planned and ongoing actions under the Phase 2 grants to address those issues :

M&E and Operational issues

The general programmatic challenges that are currently being addressed to improve indicator performance under the current Phase 2 grants are as follows;

Low acceptance and use of RDTs within both public and private health sectors with the attitude of

health care workers affecting compliance. Many patients are still treated with anti-malarial medicines

despite a negative RDT test result Planned/ongoing efforts presented in table below.

Inadequate numbers of skilled/trained health care workers to effectively manage malaria further

compounded by high staff attrition Advocacy ongoing to retain health workers, training databases

Sub-optimal leadership, management and coordination of the grants at state and LGA levels MOUs

being signed with states outlining their responsibilities + capacity building at state/LGA levels

Sub-optimal functioning and use of NHMIS manifesting in major data quality issues related to

timeliness, completeness and validity of data reported, rendering the program unable to fully reflect its

achevements at service delivery level (NMCP) Data collection tools recently harmonized and now

include data on ACTs and RDTs consumption + integrated training of health workers at sub-national

level planned in collaboration with DPRS and other programmes

Lack of a robust surveillance and monitoring system establishment of a sentinel surveillance system

is underway. Sites have been identified. In the meantime it is recommended to include a rapid impact

assessment to be conducted by the end of this year.

Planned/ongoing efforts to increase use of parasitological diagnosis

Awareness/acceptability of users (demand)

Both PRs conduct BCC as per joint a BCC plan to enhance use of and trust in RDTs/ microscopy. The effect of these activities is to be evaluated in two surveys in August 2013 – the Media Impact Survey and Social Mobilization Survey.

Capacity and awarenes of health care providers and health care workers

The PRs are providing training for health providers as well as community healthworkers. SFH is working on creating incentives for private health care administrators to attend parasitological diagnosis training (CME points) Meetings/conferences attended by medical professionals are also used to sensitize secondary and tertiary level providers - PR working with academia on supervision/QA system to improve laboratory technicians’ interpretation of RDT results - Diagnosis trainings for health providers in 2013

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- PR has finalized study in 2013 to determine whether Patent Proprietary Medicine Vendors (PPMVs) can safely conduct RDT testing

Quality control procedures for microscopy

The NMCP through its Case Management Subcommittee has established a Quality Assurance (QA) system which includes facility based quality control. Part of the QA system is adequately maintaining standards by adopting the WHO Standard Certification method to score all practitioners. Uniform Standard Operating Procedures have been developed for Public health facilities laboratories. A Diagnostic Working Group under the Case Management Subcommittee which is chaired by US Walter Reed Department of Defence has developed a checklist for facility QC and this has been field tested in facilities across the geo-political zones in the country and is planned to be rolled out.

RDT Scale up Both PRs have been asked to submit RDT scale up plans under the Phase 2 grant. NMCP has just submitted a 1

st version, which requires

significant further work. The current policy recommends the use of diagnostics in all individuals irrespective of age. While promoting microscopy at the secondary and tertiary level, the NMCP supported by Partners are providing RDTs to facility level. Both PRs have been asked to put systems in place to ensure that the implementing sites document issues from the field to inform the RDT scale up and related BCC activities. A joint program effectiveness assessment is planned by end 2013 which will include a strong focus on parasitological diagnosis.

The following issues have been noted in Pharmaceutical and Health Product Management (PHPM), which

are being addressed as follows:

Due to funding challenges it is difficult to supply all the commodities that are forecasted for (LLINs, RDTs, ACTs etc.). The demand for commodities will almost always outstrip the supply, meaning that stock-outs cannot be fully avoided. -> This proposal is trying to alleviate the shortage of commodities.

It is still a challenge to fully determine the contribution of the states when it comes to forecasting and quantification Forecasting and quantification of malaria commodities is conducted nationally to provide a national need through the support of the National Malaria PSM Technical Working Group (TWG), However states are involved in determination of needs in a bottom up approach.

The Logistics Management Information System (LMIS) not yet functional. Forecasting and quantification is mainly morbidity based due to inadequate data on consumption and patient statistics which could be used for better triangulation of data A new LMIS was introduced in Phase 1. Training and roll-out of tools has been completed for all states up to the LGA level under joint collaboration and coordination by stakeholders (NMCP,PMI, DFID, Global Fund. Additional funds were allocated in Phase 2 to complete data aggregation training and set up a database for information as well as enhancing the capability of NMCP to analyse logistics data. Long term TA is currently under negotiation with JSI to enhance forecasting and quantification and support of the LMIS.

Procurement and supply planning remains a risk. This has previously been a challenge although in the current Phase 2, better planning has even resulted in significant savings.

Central Medical Store (CMS) at Oshodi, Lagos is the central point at which commodities are received and stored before they are distributed to the states. A number of these facilities do not meet good storage standards, are dilapidated and lack proper maintenance. CMS is currently under renovation through the support of FMoH and partners. The work is expected to be completed in the second half of 2013. The next stage will be the expansion of this CMS by construction of a new ultramodern warehouse as well as another one in Abuja. The Global Fund has allocated approximately 3.1 million USD to complement about 7 millionUSD that the United States Government (USG) has set aside for this work. Through the NACA grant, 9 state stores have been earmarked for renovation, of which 8 have already been renovated and are at the stage of equipping with inventory management software, shelves, pallets and other key equipment.

Poor distribution capacity-planning and transportation In order to streamline distribution services, NMCP has now contracted 4 third party logistics service providers to distribute commodities to the states. In 9 states where PMI is also providing funding, discussions are underway to see that distribution is managed by PMI on behalf of both the Global Fund and PMI. To address challenges related to inadequate state capacity for distribution planning, NMCP is assessing state capacities with a view to addressing critical gaps. Additionally, PMI will fund a position at NMCP that will assist in the distribution planning with states among other tasks. The Global Fundgrants also have funds set aside for supportive

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supervision in the states (mentoring and coaching of staff included). The MoH Food and Drugs Services Department is gradually talking over coordination functions in liaison with state stakeholders.

3: INVESTING FOR IMPACT

3.1: Investment Request This section should describe the strategic focus of the renewal / funding requested and its scope and scale. What is the Global Fund funding and what is to be done differently to better focus investments towards impact? To what extent is national coverage achieved from all sources? What does this funding request get us to? What are the investments of other partners / governments? What are the gaps?

Background

The Global Fund has to date disbursed US$ 473,488,821 to malaria in Nigeria, constituting 8.3% of all Global Fund malaria disbursements. However, Nigeria ranks only 74 among the Global Fund’s 84 supported countries in terms of malaria disbursement received per capita.

This application and program scorecard refers to interim or “top-up” funding for the existing malaria grants under PR SFH and PR NMCP. These malaria grants went through Phase 2 renewal in May 2012 and signed their Phase 2 agreements in August 2012 for an incremental US$ 148,180,812, arriving at a total Phase 1 and Phase 2 commitment of US$ 343,720,503 (162 mln to SFH, 180 mln to NMCP).

The Global Fund announced an additional US$ 167 million interim funding allocation to Nigeria for malaria for 2013-2014, calculated as $151m to replace 26 million LLINs previously financed by the Global Fund and in need of replacement and $16m due to the program being under-allocated for the period 2013-14. In accordance with the above allocation, the CCM submitted a request of US$ 153 million to procure and distribute 26 million LLINs through mass campaigns replacing those distributed in 2009 - 2010 and US$ 14 million for the procurement of ACTs and RDTs, which are largely underfunded for the period 2013 -14.

Existing Round 8 malaria grants and supporting interventions

The existing Round 8 malaria program is based on the NMSP for 2010-2013, which is in line with the revised Abuja RBM targets towards scaling up malaria interventions and health systems strengthening. Key strategies aim to: 1) contribute to universal coverage of LLINs for disease prevention through mass campaigns and routine distribution, 2) increase ACT rollout in the public and private sector, 3) increase malaria diagnosis using microscopy at referral centers and rollout of RDTs at primary health care facilities.

An AMFm pilot component was introduced in September 2010 to facilitate more rapid achievement of universal access to high quality, affordable ACTs in all sectors, and has proved successful in reducing the price of ACTs in the private sector, increasing use of ACTs instead of montherapies and reaching hard-to-reach populations. The AMFm transition year funding for 2013 only focuses on the private sector. Specific AMFm support will be coming to an end in December 2013, but co-subsidy funding can be requested under the New Funding Model full roll out as a grant intervention.

The Phase 1 of the Round 8 malaria grants supported the country’s first national mass LLIN campaigns, through which 57,9 million LLINs were successfully distributed to date under the leadership of the NMCP with the support of partners, leading to estimated national coverage of 73% (coverage - using administrative method: 1 ITN distributed for 2 people at risk MPR 2012). The replacement of the Global Fund-supported LLINs distributed through these campaigns in 2009-2010 is the main focus of the interim funding allocation and request. Utilisation rates have remained low, however, and lessons learnt from the campaigns are being consolidated and will feed into the 2014 campaign preparation and planning.

The Phase 2 of the grants, which was signed in August 2012, included LLINs for routine distribution under the Phase 2 budget (4,559,664 LLINs for SFH and 2,545,196 for NMCP) as well as additional funding of US$ 50 million for LLIN interventions, split amongst the malaria PRs. SFH is using US$ 25 million of the funds to conduct replacement campaigns with DFID in Ogun State and LLINs for distribution through routine systems (5,400,744 LLINs). NMCP is using the US$ 25 million to fund mass LLINs campaigns (outstanding and replacement campaigns) in Delta, Osun and Sokoto States (with PMI), as well as the procurement and distribution of LLINs through routine systems (4,529,902 LLINs). World Bank funds are supporting the Delta and Osun state campaigns with operational costs.

Counterpart government funding of 20% over the US$ 50 million in the Round 8 grants for LLINs led to US$ 10 million reserved in the 2013 budget for the NMCP, which will be used to procure additional

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LLINs.

In total 17,035,506 LLINs have been or are being procured under the existing Phase 2 with a budget of U$80,507,971, which includes PSM/operational and campaign costs.

CCM Interim Funding Request

Strengths

In accordance with the Global Fund’s interim funding allocation, the CCM submitted a request of US$ 167 including US$ 153 million to procure and distribute 26 million LLINs through mass campaigns replacing those distributed in 2009 – 2010, as well as US$ 14 million for the procurement of ACTs and RDTs which are largely underfunded in the Phase 2 grant, in particular for the second half of 2014.

This investment is to complement existing programs and funding under the Round 8 Phase 2 malaria grants and will feed into the already established program structures and grant management efforts of the grants.

The proposed strategies, goals and related activities are technically sound, relevant and overall cost-effective, demonstrated to achieve impact in Nigeria and based on current globally approved strategies.

The request builds on previous experience from management and coordination of mass LLIN distribution campaigns in the country, that were first launched in 2008/9 and supported by a strong partnership of both technical and funding partners.

The allocation of one LLIN for 1.8 persons is proposed to be used to more adequately address population need as recommended by WHO in contrast to the earlier allocation of two ITNs per household. In each State targeted for replacement of previously distributed LLINs, the expected result is that: - 100% of households are reached during household registration, are registered for receiving a LLIN

and receive a voucher or coupon to exchange at a distribution point - 100% of households with a voucher or coupon attend a distribution point to exchange the voucher

or coupon for the pre-identified number of LLINs - 80% of LLINs distributed to households are hung correctly and are being used by the beneficiary

population.

The request does not propose to replace the exact net for a net procured and distributed in 2009/2010 with Global Fund financing, but instead takes into account the current coverage, the above mentioned new algorithm to determine net need, and changed financing landscape. As such the request is in line with the national plan, harmonized with other partners funding and focuses on where the impact will be made, so that the gains of the previous Global Fund investment will not be lost.

The request builds on lessons learned such as the importance of increasing BCC activities in the post campaign process, focusing on utilization. Another example is the need for a detailed microplan with the LGAs in the lead. Proper logistic and security planning are also critical other elements.

Prompt and effective case management is one of the other key objectives described in the Malaria Control Strategic Plan (NMSP 2009-2013) and procurement of RDTs and ACTs are proposed to be further supported with interim funding due to funding gaps. Investment in RDTs is fully justified based on stock outs having been identified as one of the main issues contributing to low utilisation of diagnostic testing.

Finally, the malaria commodity/programmatic and financial gaps for Nigeria have recently been revised with the support of RBM partners and clearly demonstrate the gaps and unmet need for all three commodities (LLINs, ACTs, RDTs). Please see Summary of Commodity Needs 2013-2016 on page 12.

Weaknesses:

Further analysis is needed in relation to low utilization rates and what are effective strategies to boost

correct and consistent use of LLINs.

The linkage between the mass distribution and routine distribution activities should be more clearly

explained and the latest available guidelines in this regard and LLIN distribution tracking tools should be

shared with the Global Fund.

The performance framework includes targets that are not realistic given the time frame, the work plan

and the budget e.g. RDT coverage. This should be further reviewed and revised during the grant

making process.

Considering the performance capacity of the NMCP and the logistical challenges associated with the

distribution of 26 million LLINs, it would be more prudent to assign more States for implementation of

the LLIN mass campaigns to the PR SFH.

The budgets need to be worked out as lump sums do no provide for understanding of the

reasonableness of the costs. Some budget items need to be revised e.g. unit price for RDT.

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The procurement of RDTs emphasizes the urgency to finalise the RDT scale up plan currently under

development by the PRs as a requirement under the existing Phase 2 grants.

It should be noted that there is an overlap of IRS activities and LLIN distribution in two LGAs in two out

of the nine priority states targeted for interim funding. Since the future funding situation for IRS is

uncertain, it is considered most appropriate to keep a standardised approach for LLIN distribution, both

to simplify implementation, but also to provide the population resident in IRS targeted LGAs with

personal protection when the IRS programme stops. Should IRS be continued in these areas, a non-

pyrethroid insecticide would need to be deployed.

Investment in scale up of key prevention interventions

In early 2013, RBM supported a process led by the Integrated Vector Management (IVM) sub-committee of the NMCP and states to identify LLIN coverage, gaps and needs per state and prioritise states for stages of interventions.

The processes to identify and select nine (9) States (Rivers, Ekiti, Kano, Akwa Ibom, Kaduna, Plateau, Niger, Kebbi and Katsina) to conduct replacement LLIN campaigns is based on the relevance to the needs and constraints of sustaining the Nigerian LLINs Universal strategy and malaria treatment target. The methodology used (LLIN coverage and previous campaigns held) resulted in the classification of States into 4 categories namely:

a. States with <40% coverage of households with ITNs; b. States with 41-59% coverage of households with ITNs; c. States with 60-80% coverage of households with ITNs; d. States with >81% coverage of households with ITNs.

As per the above-mentioned criteria, sixteen (16) State (criteria a & b) were selected.For these states it is projected that by 2013 coverage levels will have gone further down despite significant numbers of LLINs being delivered through routine systems. Nine (9) out of the 16 were further selected as priority States to benefit from the Interim Funding request. Funding from other Partners and Government will support the remaining States.

DFID/SunMAP will be funding an additional 3,850,000 LLINs in three of these states. The rationale for this allocation per PR is based on historical experience of the PR in that state, with NMCP taking on the majority of states as public PR. Considering the stronger performance of SFH, the Secretariat recommends that SFH takes responsibility of at least four or five states.

The procurement of these 26 million LLINs is planned for Q3 2013 and the LLINs are aimed to be distributed by the 3

rd quarter of 2014.

Pre-campaign activities consist of: planning and budgeting; resource mobilization and management; engagement of stakeholders at all levels through micro planning; training and capacity building; logistics and supply chain management; social and community mobilisation

During campaign: distribution to end-users; in-process monitoring; management of distribution sites, BCC social mobilisation activities and mass media activities.

Post campaign activities include: ensuring availability of BCC materials; assessments; hanging activities, and monitoring of use of LLINs

Experience from past BCC activities has shown positive impact on malaria control interventions eg. during the previous campaigns, the two major BCC activities were use of media such as radio and TV jingles and town announcers played key roles in mobilizing beneficiaries to collect and use the LLINs. This is demonstrated in the post campaign end process results (see results from campaigns attached). In addition, net hanging campaigns also played a key role in improving net use as demonstrated in Cross River State (see attached). The plan now is to include in the campaign process a sustained community based engagement to sensitize communities on net use. This is expected to be anchored by the community through CORPs under the supervision of an independent body. This process will be monitored by the NMCP, States, LGAs and Partners and evaluated six months later in the first instance and at the end of twelve months.

Investment in diagnostics and treatment

The CCM has requested that most of the remaining amount is used for the procurement and operational costs of ACTs and RDTs to the public sector (NMCP) allocated as per ratio of 1:3 - 3,121,951 ACTs and 9,365,854 RDTs. This will more than double the RDTs in the pipeline under Phase 2 for NMCP (7,341,439 RDTs) and help overcome critical gaps in funding until further investments are made available under the new funding model full roll out.

This ratio favouring RDTs is based on findings from national surveys (2009/10 Drug Therapeutic Efficacy Tests and 2010 NMIS) that found 35-42 % of fevers to be malaria. This indicates an estimated need of 3:1 RDTs to ACTs. Investment in RDTs is further justified based on stock outs having been

11

identified as one of the main issues contributing to low utilisation of diagnostic testing.

The procurement of 3.1 million ACTs for the public sector represent two months of stock for the 30 states supported by the Global Fund and is included to address the empty pipelines anticipated by July 2014. The ACTs are to be distributed in the second quarter of 2014. This will help to avoid a scaling down of the coverage and thus a reversal of the gains achieved. It is expected that funding under the roll out of the new funding model will have become available by that time.

The rationale for allocating the ACT and RDT commodities to NMCP is based on NMCP’s responsibility to date for the public sector procurement and distribution of ACTs and RDTs. It should be noted that in 2013 AMFm is funding co-paid ACTs for private sector , but this will cease end of 2013.

Acknowledging the underfunding situation for all commodities, as discussed by the GAC members, reprogramming of savings as well as the difference between the allocated interim funding amount and the CCM request will go into commodities, ACTs in particular. In addition to the 3.1 million ACTs requested by the CCM under the public sector PR NMCP, the Secretariat Secretariatproposes to include the additional ACTs (approximately 3,096,778 ACTs when using current AMFm prices) to be in the private sector. This will partially address Secretariat Secretariatconcerns about lack of funding for ACTs in the private sector for first half of 2014 due to ending of AMFm transition funding. These reprogrammed savings have been presented under the private sector PR budget (SFH / NGA-809-G11-M).

Supporting activities will include: robust quality assurance testing of the procured ACTs and RDTs (using newly established QA procedures under Phase 2) accompanied by efforts already in place to strengthen LMIS/ACT consumption reporting and RDT scale up, as mentioned under “2.2: Program Performance and Impact”.

Investment in improving knowledge management and implementation research on RDTs

The request includes minor amounts for technical support related to the following:

TA to the new Operational Research Unit established in April 2013 at the NMCP to collate the available evidence and research and effectively feed into programme planning and decision making (US$ 80,000)

TA and funding for activities related to the second part of RDT implementation research (US$ 208,734). This research started in Phase 1 of the malaria grant and the first part has been completed in 2012. The second part is planned to introduce measures to promote RDT utilization including improved BCC, awareness creation in the community from the health facilities by incorporating RMCs in RDT use, on-the-job training/mentoring, and improving the confidence of the healthcare providers through continued supportive supervision. TA will be focused on revision of implementation plans for the scale up of RDTs based on the implementation research.

Investments of other partners / governments

Investments will tie into those of other partners and ongoing mobilization efforts for the next round of LLIN campaigns :

PMI/MAPS: plans to support 50% of the LLINs required for Bauchi and Nasarawa states (procurement and operational costs), PSM TA at national level, M&E TA at national and state levels, promotion of continuous distribution of LLINs through antenatal clinics, school-based and community-based distribution, care and repair activities to prolong net durability and IRS in 2 LGAs.

World Bank: plans to contribute 6,449,904 LLINs in seven states for routine distribution, as well as IRSin 2 LGAs in six states under the WB Booster project.

DFID/SunMAP: 11 million LLINs in all of their intervention states (Anambra, Enugu, Kano, Kaduna, Katsina, Lagos, Niger, Ogun).

Please see details of programmatic gap table for partners’ contributions.

Additional activity recommended to be included by the SecretariatThe current Phase 2 malaria grants included M&E trainings focused on routine data reporting and capacity strengthening for state M&E officers. It is recommended that US$ 50.000 will be reserved in addition to improve availability of data through a rapid impact assessment in 2013 while supporting the roll out of a sentinel surveillance system.

Investments planned for malaria Standard Application in 2014

The above investment proposal should be seen in context of the upcoming standard NFM application, which will take into account the upcoming programs and the new National Malaria Control Plan 2014-2018. It is expected that this application will focus on scale up of diagnostics and treatment in all sectors.

Other interventions not currently covered by Global Fund funding will be considered by the country for

12

the Standard Application. It is already anticipated that the standard NFM application will request more support to IPT and possibly IRS, which are currently funded by other partners.

13

Summary of Commodity Needs, 2013- 2014

LLIN IRS RDT ACT IPTp (SP)

I. Total need 2013-2014 96,178,184 52,068,021 94,648,279 232,680,75

2 21,446,114

II. Country need planned to be covered by domestic sources

3,113,422 0 0 0 1,090,050

Federal govt 3,113,422 - - - -

State govt - - - - 1,090,050 Private sector - - - - -

III. Country need planned to be covered by other sources

24,399,906 1,420,656 12,919,611 33,425,884 0

AMFm Private Sector (excl. SFH) - - - 78,444,720 - DFID/SuNMAP/UKAID 11,000,002 - 2,800,000 2,364,180 -

PMI/MAPS 6,950,000 80,918 5,400,000 7,934,680 - World Bank 6,449,904 1,339,738 4,719,611 23,127,024 -

IV. Country need already covered by other existing GF grants

19,507,871 0 13,895,452 32,281,375 0

SFH malaria 9,960,408 - 7,480,620 8,401,670 - NMCP 9,547,463 - 6,414,832 23,879,705 -

V. Total to be covered by GF current application 26,049,677 0 7,341,439 3,121,951 0

2013 - - - - - 2014 26,049,677 - 7,341,439 3,121,951 -

VI. Remaining Gap 2013-2014 I-(II+III+IV+V)

23,107,308 50,647,365 60,491,777 163,851,54

2 20,356,064

LLINS - Numbers above refer to LLINs required for achieving and sustaining universal coverage (1 LLIN per 1.8 persons)

IRS - Measured as # households (hh). Target area: 5% of hh in 2013, 15% in 2014%, 25% in 2015 and 2016 RDTs - Needs as required in the public and private sectors

ACTs - Needs as required in the public and private sectors SP/IPTp - Measured as two (2) IPTp doses per pregnant woman

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2,800,000 3%

5,400,000 5%

4,719,611 5%

13,895,451.63 14%

7,341,439 7%

65,986,295 66%

RDT commodity funding, 2013-2014 Total needs estimate: 94,648,279 RDTs

Domestic sources

DFID/SuNMAP/UKAID

PMI

World Bank

Global Fund Round 8 Phase 2

Global Fund Interim Funding

RDT commodity gap

2,364,180 1%

7,934,680 3%

23,127,024 9%

32,281,375 12%

3,121,951 1%

120,270,843 45%

78,444,720 29%

ACT commodity funding, 2013-2014 Total needs estimate: 232,680,752 ACTs

Domestic sources

DFID/SuNMAP/UKAID

PMI

World Bank

Global Fund Round 8 Phase 2

Global Fund Interim Funding

ACT commodity gap

AMFm Private Sector (excl. SFH)

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Summary Costs (in US$) and Financial Gap related to Commodity Needs, 2013-2014

LLIN IRS RDT ACT IPTp (SP)

I. Total need 2013-2014 $ 384,712,735 $ 572,748,233 $ 34,073,380 $ 186,144,602 $ 17,982,567 II. Country need planned to be covered by domestic sources

$ 12,453,688 $ - $ - $ - $ 1,300,000

Federal govt $ 12,453,688 $ - $ - $ - $ - State govt $ - $ - $ - $ - $ 1,300,000

Private sector $ - $ - $ - $ - $ - III. Country need planned to be covered by other sources

$ 97,599,624 $ 15,627,216 $ 4,651,060 $ 26,740,707 $ -

DFID/SuNMAP/UKAID $ 44,000,008 $ - $ 1,008,000 $ 1,891,344 $ - PMI $ 27,800,000 $ 890,098 $ 1,944,000 $ 6,347,744 $ -

World Bank $ 25,799,616 $ 14,737,118 $ 1,699,060 $ 18,501,619 $ - AMFm $ - $ - $ - $ 62,755,776 $ -

IV. Country need already covered by other existing GF grants

$ 78,031,484 $ - $ 5,002,363 $ 25,825,100 $ -

SFH malaria $ 39,841,632 $ - $ 2,693,023 $ 6,721,336 $ - NMCP $ 38,189,852 $ - $ 2,309,340 $ 19,103,764 $ -

V. Total to be covered by GF current application

$ 104,198,708 $ - $ 2,642,918 $ 2,497,561 $ -

2013 $ - $ - $ - $ - $ - 2014 $ 104,198,708 $ - $ 2,642,918 $ 2,497,561 $ -

VI. Remaining Gap 2013-2014 I-(II+III+IV+V)

$ 92,429,231 $ 557,121,017 $ 21,777,040 $ 131,081,234 $ 16,284,851

Source: The information in the commodity needs and gap table above was produced in a gap analysis exercise concluded in Nairobi in February 2013 with support of RBM, and includes subsequent procurement revisions for GF commodities. This is considered more accurate than the figures in the NMSP 2008-2013. The summary costs have been estimated using current VPP procurement/PSM costs (LLIN, RDT, ACT) and country programmatic estimates (IRS and IPTp).

3.2: Funding Gap Analysis and Counterpart financing

Funding Source

Next Implementation Period

2013 2014

amount % amount %

Overall needs costing $ 597,337,248 100% $ 524,000,000 100%

Loans (World Bank Malaria Booster)

$ - 0% $ - 0%

Federal government funding

$ 10,000,000 2% $ - 0%

State government funding incl. loans and debt relief (MDG funds)

$ 51,666,609 9% $ 92,055,876 18%

Private sector contributions (national)

$ - 0% $ - 0%

Total domestic sources

$ 61,666,609 10% $ 92,055,876 18%

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Global Fund Round 8 Phase 2

$ 50,066,059 8% $ 13,973,750 3%

AMFm Private Sector (excl. SFH)

$ 60,718,612 10% $ - 0%

DFID/SuNMAP/UKAID $ 32,601,104 5% $ 30,225,000 5%

PMI/MAPS $ 60,100,000 10% $ 60,100,000 11%

World Bank $ 58,000,000 10% $ 43,735,484 9%

Total external sources $ 261,485,775 44% $ 148,034,234 28%

Total resources available

$ 323,152,385 54% $ 240,090,110 46%

Gap excl. interim funding

$ 274,184,863 46% $ 283,909,890 54%

CCM Funding Request

$ - 0% $ 167,000,000 32%

Financial gap $ 274,184,863 46% $ 116,909,890 22%

Please summarize financial needs, current and planned sources of funding and financial gap for the fight against this disease by all domestic and external sources. Please include details regarding the funding landscape and relevant information on counterpart financing.

COMMENTS TO ABOVE TABLE: The financial needs estimates have been derived from the RBM Needs Assessment as the National Malaria Strategic Plan for 2014-2018 is still under development. Data for the period 2013-2014 have been presented in line with the data available from partners in country and the period covered by the interim funding. The information in the commodity needs table above was produced in a gap analysis exercise concluded in Nairobi in February 2013 with support of RBM, and includes subsequent procurement revisions for Global Fund commodities. This above financial estimates and commodity estimates are considered more accurate than the figures in the NMSP 2008-2013 .The summary costs have been estimated using current VPP procurement/PSM costs (LLIN, RDT, ACT) and country programmatic estimates (IRS and IPTp). Domestic spending and other resources

Overall health sector budget in 2013 for Nigeria was US$ 1.7 billion according to the Federal Budget for 2013, constituting 5.8% of the total annual budget – a figure which has been relatively constant over the last years. Nigeria therefore falls seriously short of the targeted 15% of government budget for health as required by the 2001 Abuja Declaration.

The 2013 federal budget also shows that the federal government has allocated US$ 10 million for LLIN service delivery as requested by the Global Fund to match the Global Fund’s additional budget of US$ 50 mln in the Round 8 Phase 2 grants for LLINs.

No earmarked allocations for 2014 from the federal government has been provided to date. It is however anticipated that 2013 financial commitments will be maintained in 2014 and gradually increase in subsequent years in line with the April 2013, ECOWAS Town Hall Meeting on Malaria Elimination which reported that the Federal Government spending on the management and treatment of Malaria is 480 billion Naira annually. However as the CCM has not provided supporting documents to reflect this commitment, this is not reflected in the table above.

Based on the state financing budgets for malaria submitted by the CCM, the counterpart financing share for 2013-2014 is 27% and therefore meets counterpart financing requirements of 20% for lower tier low middle income countries. This requires further updating against the new financial needs estimates that followed the RBM supported commodity needs updates.

Nigeria state governments’ budgets are available while the actual expenditures are not. National Health Accounts (NHA) have been done in selected states in 1999 and 2005 but have not been institutionalized to measure the actual disease specific spending.

Due to the absence of state reporting on expenditures, the state spending on malaria has been calculated based on: 1) commitments from the states as contained in the Phase 2 and submitted State Annual Operational Plans, and are therefore not based on actual spending. This information may give us some indication about the disease specific domestic spending; bearing in mind that source of this information came from verified budget documents.

The Global Fund contribution over the years 2013-2014 excluding interim funding constitutes 8% in

17

2013 and 3% in 2014. Other partners currently address 11% (PMI), 5% (DFID), and 9% (World Bank) of the needs.

Nigeria has had constant donor support since 2007, focused on key interventions for the duration of their support. The donor partnership has proven to be complimentary and additional. Apart from the World Bank Booster Program which is due to end in 2013 and the integration of the AMFm as part of the Global Fund grant, it is anticipated that the main donors such as the PMI and DFID will continue beyond 2013, although actual commitments are currently not known.

Commodity and financial needs and gaps

Based on a gap analysis exercise for the period 2013-2016 concluded in Nairobi in February 2013 with support of RBM (reference to the commodity needstables above), including subsequent procurement revisions, indicated in programmatic gap tables above, the biggest programmatic (commodity) gaps are on ACTs while the biggest financial gaps are on LLINs.

The Global Fund Round 8 grant currently contributes 27% of the total LLIN need for 2013 (17,107,871 LLINs including 2,472,365 rolled over from Phase 1), 7% of the total need for 2014 (2,400,000 LLINs) and 0% of the total need for 2015.

Combining the existing LLINs from the Global Fund from 2013-2014 ( 19,507,871 LLINs) and the nets from the interim funding (26,049,677 LLINs), the total contribution from the Global Fund (45,557,548 LLINs) represents 47% of the total need (96,178,184 LLINs) for the period 2013-2014.

The gap analyses above indicate that the current gap is far beyond the amount expected through the interim funding. However, it is expected that the interim funding provided by the Global Fund will be a significant contribution to filling the gap in 2013 and 2014 and will be used to leverage resources from other partners, including the Government of Nigeria, the World Bank, bilateral donors and others.

There are a number of issues related to estimating programmatic gaps including, limited ACT consumption data, and demand on RDTs, which the country is working on as outlined in previous sections. Nigeria has also recognized the need to do an annual updating of the State-by-State gap analysis, bringing the States together at the zonal level to calculate gaps and look at changes in the funding landscape at State and local government area (LGA) level to ensure all contributions are captured.

4: Funding Recommendation and Budget Analysis

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Malaria Portfolio Financial Summary – Budget, Disbursements, Expenditure Period: 1 August 2009 – 31 December 2012

PR Type

No. of SSFs / Grants

Cumulative Signed Budget to cut-off

date (Grant Agreement)

Cumulative Adjusted Budget

to cut-off date (EFR)

Disbursed to cut-off date (Finance)

Expenditures to cut-off date

(EFR)

Expenditure vs. Budget

NMCP / Gov 1 $161,141,424 $161,141,424 $151,272,729 $134,969,258 ($26,172,166)

SFH / NGO 1 $136,537,786 $136,537,786 $129,820,218 $100,165,481 ($36,372,305)

Grand Total 2 $297,679,210 $297,679,210 $281,092,947 $235,134,739 ($62,544,471)

*Savings of US$5,638,405 from the procurement of health products and medicines by VPP under NMCP has been deducted from the expenditure. This is because the PR records direct disbursement to VPP by the Global Fund as expenditure.

Disbursed vs Adjusted Budget at cut-off date 94%

Expenditure vs Adjusted Budget at cut-off date 79%

Current Implementation period % time elapsed 63%

5% 1%

4%

30%

22%

12%

1% 4%

3%

1%

1% 18%

SFH: Cumulative Budget

Human Resources Technical and Management AssistanceTraining Health Products and Health EquipmentPharmaceutical Products (Medicines) Procurment and Supply Management Cost Infrastructure and Equipment Communication MaterialsMonitoring and Evaluation Living Support to clients/Target Population

6%

1%

6%

40% 27%

6%

1% 6%

3% 2% 2%

SFH: EFR - Cumulative Expenditure

19

Past performance of the PR SFH/ NGA-809-G11-M grant is A2 and PR NMCP/NGA-809-G14-M grant is B2, however the full funding amount is recommended.

Rationale for full funding recommendation

The funding from the interim grant provides an opportunity to sustain gains achieved in states where LLINs were distributed between 2009 and 2010 and are now in danger of having coverage fall to a critically low point. It also contributes to addressing underfunding in 2014 for RDTs and ACTs and bridge the Phase 2 funding with funding available under the full NFM roll out.

The proposed strategies, goals and related activities are technically sound, relevant and overall cost-effective, demonstrated to achieve impact in Nigeria and based on current globally approved strategies

The request builds on previous experience from management and coordination of mass distribution campaigns in the country, that were first launched in 2008/9 and is supported by a strong partnership of both technical as well as funding partners.

Overall the lead implementer (NMCP) has not performed adequately but demonstrated the ability to improve on its performance. NMCP’s programmatic results were significantly affected by the delay in the procurement and delivery of health products and medicines.

The Secretariat proposes that SFH takes responsibility for 5 out of the 9 states in terms of the LLIN mass distribution campaigns.

The PRs have considerable experience in executing the Global Fund’s Malaria grant and have adequate absorption capacity.

The new NMCP National Coordinator has demonstrated strong commitment and leadership (setting the right tone at the top). She is at the forefront of implementing the necessary changes at NMCP and country wide coordination of malaria control efforts.

98% of the interim funding budget is mapped to procurement and PSM related cost of health products and medicines, of which about 70% will be disbursed directly to VPP for the procurement and delivery of the LLINs, ACTs and RDTs.

Risk mitigation measures as outlined under previous Sections 2.1 and 3.2.

New Management Actions as outlined in Section 5.

3% 3% 4%

48% 15%

4%

1%

2% 4%

1% 1%

16%

NMCP: Cumulative Budget

Human Resources Technical and Management AssistanceTraining Health Products and Health EquipmentPharmaceutical Products (Medicines) Procurment and Supply Management Cost Infrastructure and Equipment Communication MaterialsMonitoring and Evaluation Living Support to clients/Target PopulationPlanning and Administration Overhead

3% 4% 3%

58%

17%

1%

1% 2%

2% 7%

NMCP: EFR - Cumulative Expenditure

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Ongoing risk mitigation measures:

The strategic investments proposed by the Secretariatare supported by the following risk mitigation measures:

Procurement through Voluntary Pooled Procurement (VPP). The LLINs will be delivered to state level and in a phased approach to decrease congestion at the port and decrease other logistical challenges related to in-country transportation, as is being done for the other LLINs procured through Phase 2 funding delivered to state level and which has shown good results. Recent efforts to improve the VPP arrangement and collaboration between the PRs and the VPP implementers has resulted in improved delivery planning in Phase 2 – this will be key in planning the arrival of the LLINs at the LGA level, which has been indicated as paramount in previous campaigns;

Timely identification and contracting of logistics agents as in past campaigns;

Built on lessons learned from overall campaign management and BCC activities which will need to feed into the current campaign planning and preparation. LLIN tracking tools have been developed.

Strong collaboration with and support from partners (details outlined above) notably RBM, PMI, US govt/PEPFAR (support at the central level on strengthening the supply chain with other technical partners) and World Bank;

New existing investments in technical assistance at the PR/NMCP national level including: 1) Program Management, 2) Financial Management, 3) Pharmaceutical Supply Management and 4) Monitoring & Evaluation at both the PR/national and state levels;

Strengthening of the NMCP financial management system through restructuring, recruitment of qualified finance and internal audit staff, strengthening of the internal audit function, and ongoing reviews as described under Section 2.2: Program Performance and Impact. A special LFA review to further assess the control environment is almost finalized and report findings and recommendations will be incorporated into the PR’s capacity building plan. The new National Coordinator has demonstrated strong commitment and leadership to address the recommendations and requirements made by theGlobal Fund.

The capacity of NMCP’s 12 new SR states to implement their activities as SRs and the functionality of the signed PR-state MOUs with regards to PHPM and tracking of state expenditures will be reviewed in Q4 2013.

Additional Management Actions as outlined in “Section 5: Further contextual Information”;

All of the above will be added to/supplement the ongoing grant management and risk mitigation efforts under the Round 8 malaria grants, including Global Fund reviews and approvals of the in-state distribution arrangements for NMCP, quarterly stock updates, TA to support the newly established LMIS in becoming operational (ACT reporting) – please see QUARTs for reference.

Secretariat funding recommendation: The CCM request did not split the budget between the two PRs SFH and NMCP, although a programmatic allocation was made. In this allocation all ACT and RDT procurement/activities were assigned to NMCP, as well as seven states for LLIN interventions (Plateau, Kaduna, Kano, Katsina, Kebbi, Akwa Ibom, Rivers). The CCM programmatically assigned two states, Niger and Ekiti to SFH. Given the performance of SFH, the Secretariat proposes to reallocate two additional states (Kaduna and Kano) to SFH. The LLIN procurement and operational budget has been allocated per PR on the basis of the number of LLINs to be distributed in the relevant states. The actual allocation per PR will be done during grant negotiation.

Budget adjustments

Health Products and Health Equipment: Adjustment mainly as a result of the CCM using higher unit costs than the international reference prices (1,849,757)

Adjustments to average unit cost of RDTs per unit (-$1,873,171),

Increase in unit cost fo Sharps boxes to $1.25 p/unit (+$23,415) Pharmaceutical Products (Medicines) Adjustment mainly as a result of the CCM using unreasonable unit costs (404,917)

Cost of developing and producing ACT consumer information for private sector taken out because the drugs are meant to be distributed in the public sector according to the CCM Request

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Procurement and Supply Management Cost Adjustment mainly as a result of the CCM using higher unit costs than those acceptable based on historical costs (192,614)

Reduction of unit cost per LLIN delivery from port of entry to LGA stores including off-loading to 0.13 c/net in yr 4 (-$6,512,419);

Increase in unit cost for freight from origin to port of entry to 0.45 c/net in yr 3 (+$10,862,715); and

Various adjustments to unit cost per net for freight, quality control, delivery and insurance costs for LLIN, RDT and ACT procurement (-$4,542,910.46)

Total Adjustment: ($ 2,447,288)

There are a number of areas that will be further refined during the negotiation stage. The unit costs of commodities are based on the most recent international reference prices as well as those achieved through VPP, which will primarily procure most of the products. The PSM costs, which also form a large proportion of the budget are based on the most recent achieved costs. The operational costs for LLIN mass campaigns will be further negotiated. Acknowledging the underfunding situation for all commodities, as discussed by the GAC members, reprogramming of savings (currently US$ 2,447,288 as reflected above, further savings to be identified in grant negotiations) as well as the difference between the allocated interim funding amount and the CCM request (US$ 167,000,000 - US$ 166,925,570 = US$ 74,430) will go into commodities, ACTs in particular. In addition to the 3.1 million ACTs requested by the CCM under the public sector PR NMCP, the Secretariat proposes to include the additional ACTs in the private sector. This will partially address Secretariat concerns about lack of funding for ACTs in the private sector for first half of 2014 due to ending of AMFm transition funding. These reprogrammed savings have been presented under the private sector PR budget (SFH / NGA-809-G11-M). Final Budget: US$ 167,000,000 While acknowledging that the grant is 98% commodities (health products, medicines and PSM cost), there are still cost categories which are presented as lump sums and the details should be obtained during grant negotiation. This concerns: 1.HR -$340K, TA $446K,Training $62k ,Planning and Admin $451k, Infrastructure and equipment -199k,M&E 243 and Overheads -184k. Budget Assumptions

The funding limit available for PR is US$ 167,000,000. The recommended budget is US$ 167,000,000, which is within the available funding limit.

Further additional reductions could be realized upon further detailed review at the time of grant making for costs related including HR, Training, Overheads etc. are provided by the CCM for review.

3. Summary Budget Recommendation and Incremental Amount

2013 after cut-off date

2014 Total

Total Budget requested by the CCM (after cut-off date for the

next Implementation Period) US$ 102,901,420 US$ 64,024,150 US$ 166,925,570

Health Products and Health Equipment

(US$ 1,849,757))

(US$ 1,849,757)

Medicines and Pharmaceutical Products

(US$ 404,917)

(US$ 404,917)

Procurement and Supply Management Costs

US$ 9,501,557 (US$ 9,694,171)

(US$ 192,614)

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2013 after cut-off date

2014 Total

Reprogrammed savings for ACTs US$ 2,521,718 US$ 2,521,718

Total Budget Recommended by the Secretariat

US$ 112,670,021 US$ 54,329,979 US$ 167,000,000

- Undisbursed amount at cut-off date N/A

- Cash at cut-off date N/A

RECOMMENDED INCREMENTAL AMOUNT US$ 167,000,000

TRP Clarified Amount for the Next Implementation Period US$ 167,000,000 Inc amount as a % of adjusted TRP clarified amount (cannot exceed 100% of adjusted TRP clarified amount)

100%

5: Further contextual Information Please add any other comments/ observations from the the CT to bring to the GAC/ TRP’s attention regarding the renewal/ funding request. Please summarize relevant Conditions / Management Actions (if any) reflecting the key risks in the grant.

23

Grant making process The Secretariat proposes that the following will be clarified during grant making and reflected in the final amended grant agreement:

Performance Framework targets need to be further clarified against reporting periods, past performance and available budget. This includes the RDT scale up targets and should be accompanied by an updated RDT scale-up plan.

Budget details and PSM costs need to be further clarified and scrutinized. The break down of ACTs to be procured needs to be corrected.

PRs are to submit updated PSM plans including delivery schedules.

The latest available guidelines in relation to the linkage between the LLIN distribution by mass campaigns and routine should be submitted to the Global Fund.

Additional management actions (in addition to existing risk mitigation measures) The Secretariat proposes the following management actions in addition to the risk mitigation measures that are ongoing under the Phase 2 grant, which can be addressed after the amended grant signing:

Effectiveness of BCC activities: PRs to submit an updated joint BCC plan reflecting the analysis of the

results of the Media Impact survey and Social Mobilisation survey and other relevant findings from BCC

evaluation reports related to the past LLIN campaigns: By August 2013

Lack of effective post campaign monitoring mechanisms to provide valid, complete and accurate data on the LLINs distributed (ownership and use). A clear, simple, quick and feasible assessment tool for implementation of post-campaign activities should be developed to assess availability of the distribiuted nets utilization by at household memebers. By 1

st October 2013.

There is reported high ownership of LLINs but low utilization at the household level. Operational research should be conducted to further understand the factors contributing to low usage of LLINs despite levels of ownership. By 1 April 2014.

Reconciliation of LLINs (both routine and distribution) at the national level has been a challenge. LLIN tracking database is being developed and should be reviewed in view of the linkage of the mass and routine distribution channels. Periodical analysis should be done to inform planning and forecasting. By August 2013

Storage capacities: Identification and assessment of specific stores to be used for the interim storage of LLINs at the State Level to ensure that they have the adequate conditions to store these LLINs and adequate security to safeguard the assets: Process should start three months prior to arrival of shipments at each state.

Sub-optimal routine M&E systems: A revised M&E is to be agreed with the PRs to strengthen the

NHMIS and DHIS2 for improved surveillance, monitoring and reporting (incl. sentinel surveillance

systems), and institute regular malaria surveys and rapid impact assessments. This should take into

account the actions to improve national reporting, currently under development with NMCP: By 1

September 2013. The PRs will be requested to submit regular updates in their PUDRs regarding progress made on

recommendations from the Malaria Program Review 2012, the recent 2013 On Site Data Verification and Data Quality Audit conducted by the Global Fund.

ANNEX 1: PERF

24

ANNEX 1: PERFORMANCE BY PRINCIPAL RECIPIENT

PRINCIPAL RECIPIENT 1 - SOCIETY FOR FAMILY HEALTH (SFH) Grant Number NGA-809-G11-M

Principal Recipient Society for Family Health (SFH)

Current Grant Start date 01/09/2009

Current Grant End date 31/10/2014

Programmatic Achievements Overall Performance Rating to cut-off date: SFH

Aug 1 2009 - Dec 31 2009

Jan 1 2010 - Mar 31 2010

Apr 1 2010 - Jun 30 2010

Jul 1 2010 - Sep 30 2010

Oct 1 2010 - Dec 31 2010

Jan 1 2011 - Mar 31 2011

Apr 1 2011 - Jun 30 2011

Jul 1 2011 - Sep 30 2011

Oct 1 2011 - Dec 31 2011

Jan 1 2012 - Mar 31 2012

Apr 1 2012 - Jun 30 2012

Jul 1 2012 - Dec 31 2012

A2 A2 B1 B2 B2 B2 B2 B1 B1 B2 B2 A2

Rated Period :

Period

01.Jul.2012

Period

31.Dec.2012

Top 10

Train. # Active Indicator Name Target Result Percentage

Period Value Period Value

Top 10

1.2 (1.3) Number of LLINs distributed through private sector to end users

11 3,390,609 11 3,153,248 93%

Top 10

2.2 (2.3) Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines through the private sector (SFH) (Indicator 2.2 in Phase 1 Performance Framework)

12 848,935 12 616,151 73%

Top 10

2.4 (2.6) Number of persons 5 and above with uncomplicated malaria receiving ACT treatment according to National guidelines through the private sector (Indicator 2.4 in Phase 1 Performance Framework)

12 1,251,482 12 1,204,996 96%

2.5 (2.9) Percentage of participating health facilities in the private sector reporting no stock out of ACTs for 1 week or more within the last 3 months (Indicator 2.6 in Phase 1 Performance Framework)

12 N: D:

P: 50 %

12 N: D:

P: 59 %

118%

Top 10

2.10 (2.7) Number of ACT treatment doses distributed for children under five through the private sector wholesalers

12 1,273,403 12 1,332,288 105%

Top 10

2.11 (2.8) Number of ACT treatment doses distributed for people over five through the private sector wholesalers

12 1,877,224 12 4,530,952 120% *

3.10 (3.3) Percentage of all suspected malaria cases that received a parasitological test through the private sector

12 N: 1,320,109 D: 27,702,921

P: 4.8 %

12 N: 24,085 D: 27,702,921

P: 0.1 %

2%

Top 10

4.2 Number of communities and groups reached through social mobilization activities (SFH) (Indicator 4.1 in Phase 1 Performance Framework)

12 2,944 12 1,785 61%

25

Top 10

Train. 5.2 (5.3) Number of health care providers trained in malaria case management and prevention (Private Sector) (Indicator 2.7 in Phase 1 Performance Framework)

12 360 12 353 98%

Top 10

Train. 5.3 (5.4) Number of health workers trained on the use of RDTs in malaria diagnosis (Indicator 3.7 in Phase 1 Performance Framework)

12 360 12 333 92%

Performance Rating

All Indicator or Top Indicator Score

A1 >100

A2 90%-100%

B1 60% - 89%

B2 30% - 59%

C < 30 %

AVG performance on TRAINING Indicators

95%

AVG performance on TOP TEN indicators (including TRAINING)

92%

TOP TEN indicators rating A2

AVG performance ALL indicators

86%

ALL indicators rating B1

umber of TOP TEN indicators with B2 or C Rating

0

Quantitative Indicator rating A2

RECOMMENDED PERFORMANCE RATING A2

26

Risk Heat Map SFH

RY PRINCIPAL RECIPIENT1

PRINCIPAL RECIPIENT 2 - NATIONAL MALARIA CONTROL PROGRAM (NMCP) Grant Number NGA-809-G14-M

Principal Recipient National Malaria Control Program (NMCP)

Current Grant Start date 01/11/2009

Current Grant End date 31/01/2015

Programmatic Achievements Overall Performance Rating to cut-off date: NMCP

Nov 1 2009 - Dec 31 2009

Jan 1 2010 - Mar 31 2010

Apr 1 2010 - Jun 30 2010

Jul 1 2010 - Sep 30 2010

Oct 1 2010 - Dec 31 2010

Jan 1 2011 - Mar 31 2011

Apr 1 2011 - Jun 30 2011

Jul 1 2011 - Sep 30 2011

Oct 1 2011 - Dec 31 2011

Jan 1 2012 - Mar 31 2012

Apr 1 2012 - Jun 30 2012

Jul 1 2012 - Dec 31 2012

B1 B1 B2 B2 B2 C B2 B2 B2 C B2 B2

1 This section needs to be repeated for each PR in the portfolio.

27

Rated Period :

Period

1 Jul.2012

Period

31 Dec.2012

Top 10

Train. # Active Indicator Name Target Result Percentage

Period Value Period Value

Top 10

1.1 1.1 Number of LLIN distributed to public and private users (Indicator 1.0 "Total number of LLIN distributed to end users (national)" in Phase 1 Performance Framework)

12 4,925,778 12 4,135,540 84%

Top 10

1.2 1.2 Number of LLIN distributed through public sector to end users (Indicator 1.1 in Phase 1 Performance Framework)

12 2,150,383 12 0 0%

Top 10

2.1 2.1 Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines through Private and Public sectors (Indicator 2.0 "Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines (national)" in Phase 1 Performance Framework)

12 5,715,729 12 1,391,653 24%

Top 10

2.2 2.2 Number of children under five with uncomplicated malaria receiving ACT treatment according to National guidelines through the public sector (NMCP) (Indicator 2.1 in Phase 1 Performance Framework)

12 1,975,200 12 777,502 39%

Top 10

2.3 2.4 Number of people (over 5) with uncomplicated malaria receiving ACT treatment according to National guidelines through public and private sectors (national) (Indicator 2.3 "Number of people (over 5) with uncomplicated malaria receiving ACT treatment according to National guidelines (National)" in Phase 1 Performance Framework)

12 5,418,077 12 1,621,605 30%

Top 10

2.4 2.5 Number of people (over 5) with uncomplicated malaria receiving ACT treatment according to National guidelines through the public sector (NMCP) (Indicator 2.4 in Phase 1 Performance Framework)

12 2,238,866 12 1,606,816 72%

3.10 3.0 Percentage of participating health facilities in the public sector reporting no stock out of ACTs for 1 week or more within the last three months (Indicator 2.5 in Phase 1 Performance Framework)

12 N: D:

P: 50 %

12 N: D:

P: 32 %

64%

3.11 3.1 Percentage of all suspected malaria cases that received a parasitological test through the public and private sectors

12 N: 4,318,653 D: 46,171,535

P: 9.4 %

12 N: 461,715.4 D: 46,171,535

P: 1 %

11%

3.12 3.2 Percentage of all suspected malaria cases that received a parasitological test through the public sector

12 N: 1,046,154 D: 7,190,715

P: 14.5 %

12 N: 431,442.9 D: 7,190,715

P: 6 %

41%

Top 10

Train. 5.1 5.1 Number of health care providers trained in malaria case management (Public Sector) (This indicator has been reclassified from objective 2 (2.7) to 5 (5.1) in Phase 2.)

12 7,164 12 0 0%

28

5.2 5.2 Number of health care providers trained on Logistics Management Information Systems/Malaria Commodity Logisitcs System in the public sector

12 2,148 12 2,467 115%

Performance Rating

All Indicator or Top Indicator Score

A1 >100

A2 90%-100%

B1 60% - 89%

B2 30% - 59%

C < 30 %

AVG performance on TRAINING Indicators

0%

AVG performance on TOP TEN indicators (including TRAINING)

36%

TOP TEN indicators rating

B2

AVG performance ALL indicators

44%

ALL indicators rating B2

Number of TOP TEN indicators with B2 or C Rating

5

Quantitative Indicator rating

B2

RECOMMENDED PERFORMANCE RATING B2

29

Risk Heat Map NMCP