PROGRAM SCORECARD. Tanzania. Malaria 1. SUMMARY OF RECOMMENDATION. Interim Funding Amount (if applicable)

PROGRAM SCORECARD Tanzania Malaria 1. SUMMARY OF RECOMMENDATION Grant number TNZ-M- MOFEA PR name Ministry of Finance of the United Republic of Tanzania Performance Rating & Recommendat ion Category Interim Funding Amount (if applicable) % of Adjusted TRP clarified amount (or % of total Interim Funding) % saving B1 NA NA NA Comments HOST GRANT includes AMFm component after consolidation between G11 and G01 (R7 and R9) TNZ- 809-G11- M TNZ-102- G01-M Ministry of Finance of the United Republic of Tanzania Ministry of Finance of the United Republic of Tanzania B1 US$ 114,000,000 NA NA A1 NA NA NA Phase 2 Approved / unsigned / consolidated with the host grant Last year (11 th ) of RCC Change of PR from MoH to MoF at consolidation Total Adjusted TRP clarified Amount (by PR) [renewals only] Total Recommended Incremental Amount (all PRs) NA US$ 114,000,000 Background: This Program Scorecard describes the overall program performance, impact and risk mitigation of the Tanzania malaria portfolio. The investment section, however, focuses only on the additional request under the interim funding of the New Funding Model (NFM) to be approved by the Grant Approval Committee (GAC). The main SSF grant, TNZ-M-MOFEA, underwent periodic review in March 2013, at which time the GAC requested that the Secretariat consolidate all three existing malaria grants, and add the interim funding to the resultant grant. The GAC requested to review the final, consolidated disbursement-ready grant to be recommended to the Board for approval before signing. As a result, this application for interim funding is embedded in a new grant after the consolidation of the three existing Tanzania malaria grants: TNZ-M- MOFEA, which funds case management and private sector co-payment integration (AMFm), TNZ-809- G011-M funding universal access to long-lasting insecticidal nets (LLINs) and monitoring and evaluation (M&E), and TNZ-102-G01-M that supports BCC interventions, and previously LLINs for children under five years of age (U5) and pregnant women through the Tanzanian national voucher scheme (TNVS). 1

The total budget of the consolidated malaria grant is US$ 224,768,836 and includes US$ 114,000,000 of the interim funding allocation. The grant period is 1 July 2013 30 June 2016, which follows the country s fiscal cycle. This Program Score Card therefore describes the details of the interim funding for the continuation of Round 8 malaria grant which will now be consolidated with the other grants - that focuses on: (Objective 1) distribution of LLINs to the general population through a mass campaign to achieve universal coverage; (Objective 2) strengthening malaria infrastructure at the regional level; and (Objective 3) laying the foundation for defining the mechanisms for the sustainable maintenance of universal LLIN coverage in the future. The grant went through Phase 2 renewal in October 2011 as a clear Go and a zero incremental amount. Phase 2 of this grant was never signed due to the Board Condition that required the Principal Recipient, the Ministry of Finance, to refund US$ 2,356,453 to account for the rate of exchange losses that it incurred during the period January-July 2010. The Principal Recipient agreed on 26 September 2012 to refund the National Malaria Control Program for the exchange losses incurred during the implementation period. The refund is spread out in three phases of US$ 785,485 each. The first installment was transferred to the Ministry of Health in March 2013 thus allowing the grant to be extended through consolidation with the other existing malaria grants. The full refund is included in the consolidated grant s budget allocation (Ref. grant consolidation workings table on page 5). Through the Round 8 malaria grant, Tanzania achieved LLIN universal coverage in October 2011 when approximately 18 million bednets were distributed to the general population through mass campaigns and approximately 7 million bednets through routine distributions to target population under Round 1 RCC grant. To maintain the gains achieved through the universal mass campaigns, US$ 114 million of interim funding was allocated to the program for the transition period (2013-14) in the category of service interruption. The service interruption costs were calculated based on the estimated funding required for the replacement of LLINs previously purchased by the Global Fund in order to sustain coverage with this key intervention. In accordance with the above allocation, the Tanzania Country Coordinating Mechanism (TNCM) submitted a request of US$ 116 million to replace LLINs through a mass campaign. The request is in line with the LLIN Strategic Plan which aims to achieve and maintain universal access to LLINs in order to have at least 80% appropriate use. 2: EPIDEMIOLOGICAL CONTEXT AND PROGRAM PERFORMANCE 2.1: Epidemiological Situation and Country Context Tanzania has an estimated 43.2 million people living in 21 regions, 113 districts, around 10,300 villages and 10 million households. Tanzania has the third largest population at risk of malaria in Africa, after Nigeria and DRC. Malaria is endemic, with approximately 40 million inhabitants living in malaria transmission areas. Plasmodium falciparum accounts for 96% of malaria infections (Malaria Medium Term Strategic Plan, 2008-13). Unstable seasonal malaria transmission continues in approx. 20% of the country, while stable malaria with seasonal variation occurs in another 20%. The remaining 60% malaria endemic areas are characterized as having stable perennial transmission. The intensity of malaria transmission can be mapped into three distinct geographical zones (see below maps); the central part of Tanzania from Arusha in the north all the way down to Dodoma and Mbeya regions have the lowest transmission whereas the Lake Regions and southwestern regions have the highest transmission. The rest of the country has moderate transmission. The most vulnerable groups are children under five years of age and pregnant women. The Annual Health Statistics Abstract report for 2011 shows that malaria is still a major public health problem, accounting for 40% of the outpatient cases (about 14-18 million reported malaria cases annually) and ranking number one at the outpatient setting. In addition, malaria is reported through inpatient health records as the primary cause of death among children. Figure 1- THMIS 2007/8 2

Figure 2 -THMIS 2011/12 Malaria Prevalence (P. falciparum) in Children (6-59 months) THMIS (2007/2008): 18% THMIS preliminary results (2011/12): 10% Findings from the 2011-2012 Tanzania HIV/AIDS and Malaria Indicator Survey (THMIS 2012) indicate significant health improvements and in malaria prevalence as a result of the successful interventions against malaria in comparison to the 2007/2008 THMIS Survey. In addition, all causes of infant mortality and U5 3

mortality were reported to decrease between 1999 and 2010 (DHS): Prevalence of malaria parasite infection in U5 children declined from 18% in 2007/8 to 4% in 2012 (THMIS): The overall prevalence of malaria in U5 children is 10% as measured by RDT (4% by microscopy), a 45% decrease in prevalence since the THMIS 2007/8. Prevalence increases with age, from 4% in infants (6-11 months) to 12% in children aged 48-59 months, and varies across regions. The corridor of low prevalence ( 3.3%) runs from north to south of the country. However, severe anemia (6% of children) tends to decline with age in contrast to malaria prevalence. 95% of households owned some type of mosquito net, with no difference in urban rural stratification - an increase from 75% in 2010; Increase in ownership of LLINs from 64% to 91% (THMIS); Use of ITNs also increased from 57% to 75% (THMIS); Significant contribution to the reduction in all-cause infant mortality (IMR) from 99/1000 (1999) to 68/1000 in 2004/05 to 51/1000 in 2010; U5 mortality reduced by 45% from 148/1000 (1999) to 81/1000 in 2010. Partnership environment for malaria The NMCP is supported by a strong network of partners through NATNETS Steering Committee that will soon be integrated into the Vector Control Technical Committee as a part of the newly forming Malaria Control Steering Committee. Roll Back Malaria (RBM) NATNETS partners are well represented in Tanzania and provide support to the NMCP through technical and policy working groups under national leadership contributing to harmonization of activities 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 three regions (LLINs distribution under the School net campaign and IRS. Collaboration focuses on supply chain management, and M&E, e.g. national HMIS-DHIS strengthening and roll-out. The UK Department for International Development (DFID) supports malaria control interventions under TNVS program for pregnant women and U5 s. The Swiss Agency for Development and Cooperation (SDC) has been providing technical assistance to the NMCP since 2002 through the NETCELL Project which is managed by the Swiss Tropical and Public Health Institute. Secretariat guidance to the Tanzania CCM on interim funding request as a part of grant consolidation In April 2013, the Global Fund announced the additional US$ 114 million of interim malaria funding allocated under the NFM to Tanzania. During the periodic review of the single stream of funding (SSF) grant in March 2013, the GAC acknowledged that Tanzania is also an interim applicant for the NFM. The GAC encouraged use of the Board-approved grant consolidation decision to further align with the principles of the New Funding Model. The Secretariat was therefore tasked to consolidate all three active malaria grants in Tanzania into one grant and to incorporate the activities to be funded under the NFM (principally LLINs procurement and distribution to maintain the universal access target). The GAC requested to review the final, consolidated, disbursement-ready grant that incorporates the interim funding allocation for the Board approval before grant signing. The plan was communicated to CCM and stakeholders during the Global Fund country visit in April 2013; the consolidated grant was negotiated through the dialogue process in June 2013 and now incorporates interim funding for LLINs. The interim funding request was developed under the guidance of the TNCM, with the involvement of the NMCP, RBM Partnership, PMI, SDC, WHO and other stakeholders. The RBM funded consultant supported grant consolidation planning during the period of two weeks in May 2013. Grant consolidation workings: Rounds / Grants / NFM R1 RCC R8 R9 SSF (R7 & R9) NFM Allocation TOTAL Undisbursed Amount - Phase 1 1,536,92 6,055,144 15,789,174 23,381,245 4

Released Commitment 55,474 Unreleased Commitments 4,214,072-14,994,560 19,208,632 Cash Balance from Phase 1-958,212 1,788,615 2,746,827 Rate of Exchange Loss to 2,356,453 2,356,453 be Refunded to NMCP - Interim Funding Allocation - - - 114,000,000 114,000,000 SSF Incremental Amount - - 63,173,020 63,173,020 5,806,473 9,369,809 95,745,369 114,000,000 224,866,177 2.2: Program Performance and Impact Progress towards impact (also refer to figures 1&2 above) INDICATOR Baseline (2010) 1 2 Achievement (2012) 3 National Target Global Target IMPACT All-cause under 5 mortality rate 81/1000 NA 54/10000 Malaria parasite prevalence in children under five years of age 18% 10% 5% OUTCOME Proportion of pregnant women who slept under an ITN the night preceding the survey 57% 75% 80% 80% Proportion of children under five years of age who slept under an ITN the night preceding the survey 64% 72% 80% 80% Proportion of all household members who slept under an ITN the night preceding the survey 45% 68% 80% 80% COVERAGE Proportion of households with at least one ITN 63% 91% 90% 80% Proportion of households with one LLIN for every two people LLINS Coverage and Use NA 75% 80% 80% The results of the THMIS 2011/2012 reveal that over 91% of all households in Mainland Tanzania own at least one Insecticide Treated Net (ITN) or LLIN, with an average number of 2.2 nets per household. Seventyfive percent (75%) of the population have access to an ITN and 68% of the general population slept under an ITN the night before the survey (THMIS 2011/12). There is however considerable regional variation in household access, from 60% in Geita Region, to 91% in Lindi region (refer to below figures). While these are improvements compared to baseline in 2007-2008, scale-up is needed to reach the RBM Abuja Declaration Target of 80% coverage. 1 Source for the impact indicator: Tanzania HIV Malaria Indicator Survey (THMIS) 2007/2008; National Bureau of Statistics and Macro International 2 Source for the outcome and coverage indicators: Tanzania Demographic and Health Survey (DHS) 2010; National Bureau of Statistics and Macro International 3 Tanzania HIV Malaria Indicator Survey (THMIS) 2011/2012; National Bureau of Statistics and Macro International 5

Chart 1: Household Access and Use of LLINs (Source: THMIS 2011/12) Use in Key Affected Population - Pregnant Women and Chidren Under 5 - MDG Target of 8O% Nationwide, use of mosquito nets by children has increased 8 percentage points since the 2010 TDHS while the use of mosquito nets by pregnant women has more than doubled since the 2007-08 THMIS. Tanzania Malaria Portfolio performance TNZ-102-G01-M: The overall grant performance rating for the Round 1 Rolling Continuation Channel (RCC) Phase 1 was A2 with good programmatic performance and grant management. The focus of this grant under RCC Phase 1 was on the Under Five Catch-Up Campaign and the continuation of the Tanzania National Voucher Scheme. The focus of the RCC in the grant s 10 th year is on BCC - stimulating/expanding utilization of ITN/LLIN and transforming public perception and adherence to malaria prevention. Performance against key performance indicators: - Proportion of respondents who have heard the phrase 'malaria haikubaliki' or malaria is not acceptable (88.8% vs. target of 80%, 111% of achievement) - Proportion of respondents who believe they can protect themselves from getting malaria (82% vs. 6

target of 80%) - Proportion of respondents who intend to sleep under a bed net every night of the year (93% vs. target of 80%) - Proportion of caregivers who believe they could get all of their children under five to sleep under a bed net (80% vs. target of 80.7%) TNZ-809-G11-M: The overall grant performance rating for the Round 8 Grant which funded the Universal Coverage Campaign was B1 dated 31 October 2011. The grant agreement for the second phase has not been signed due to unmet Board condition which arose from the exchange rate loss during LLIN procurement. This Board condition has now been resolved with the Ministry of Finance having paid the first of the three equal tranches to the NMCP in March 2013, as detailed in the background section above. Performance against key performance indicators: - LLIN distribution of 17,738,974 million bed nets, compared to the targeted goal 21,830,370 million (81% achievement), through a partnership of the Global Fund with the World Bank, PMI, DFID, SDC and other stakeholders, - 28,177 ward executive officers have been trained or retrained in the registration and the management of net distribution, against a target of 32,827 (86% achievement). TNZ-M-MOFEA: The overall performance is B1. The grant focuses on improved malaria case management through improved access of antimalarials, and better diagnosis such that by 2015, 80% of malaria patients will receive effective treatment of antimalarials. This grant was reviewed by the GAC in March 2013. Overall Financial Performance: The Global Fund has so far committed US$ 331,112,206 and disbursed US$ 307,675,488 through five malaria grants. Current on-going grants: TNZ-102-G01-M (committed US$78,622,898, disbursed US$ 77,030,497), TNZ-809-G11-M (committed US$ 100,427,017, disbursed US$ 94,371,873), TNZ-M-MOFEA (committed US$ 60,569,059, disbursed US$ 44,869,885, Phase 2 approved incremental amount US$ 63,173,020). The malaria portfolio in Mainland Tanzania has had low absorption rate. This was attributed to delayed reporting and disbursements to the PR, slow funding flows to SRs, and the delayed procurement in the public sector which affected the health products availability at the facility level, in turn affecting the programmatic results. As much of the procurement was done in response to the emergency situations which could have been avoided if the funds were available in time to warrant regular procurement processes, major efficiencies are expected with the introduction of VPP for ACT, RDT and LLIN, proper planning and timely disbursements. It is important to note, however, that some of the procurement delays were beyond the control of the PR and SRs, such as the lack of AMFm sufficient funds to finance the public sector procurement of ACTs during Phase 1 of the SSF grant. In the upcoming period, and with the support of the technical partner (GMS), the PR is expected to also adequately address the SR financial management issues so as to minimize the re-occurrence of inadequately supported expenditures, VAT payments, spending on unbudgeted categories and foreign exchange losses. Program Management: Lack of Program Management Unit at the Ministry of Finance to coordinate and oversee the grants has led to recurrent delays in submission of progress updates and disbursement requests (majority of PUDR processed were over six months old) and delays in fulfilling Condition Precedent/Special Conditions (CP/SP). On occasions all unfulfilled CPs/SPs had to be waivered to make emergency disbursements for the procurement of health products to avoid stock-outs. As per request of the GAC, the country has consolidated all three malaria grants, with the interim funding, into one grant. The risks associated with the various grants have been reviewed and are being integrated as necessary into the new grant agreement. 3: INVESTING FOR IMPACT 3.1: Investment Request This section describes into detail what has not been covered by the recent SSF Periodic review which was approved by GAC in April 2013. In response to the Global Fund s interim NFM allocation, the CCM submitted a request for US$ 116 to procure and distribute approximately 18.9 million LLINs through mass campaigns in order to replace those distributed in 2010 2011. This investment is expected to complement the existing programs and funding 7

under the SSF malaria grants and will feed into the already established program structures and efforts. The proposed strategies, goals and related activities are technically sound, relevant and cost-effective; they are demonstrated to achieve the impact in Tanzania and are based on the globally approved strategies. The request for interim funding builds on the previous experience from management and coordination of mass LLIN distribution campaigns that were first launched in 2010/11 and supported by a strong alliance of both technical and funding partners. The NMCP is currently in the process of developing its new Mid-Term Malaria Strategic Plan for the period 2014 2020. The main technical strategies in this Plan are: (1) Malaria diagnosis and treatment; and (2) Integrated malaria vector control (IMVC). These are supported by three cross-cutting strategies: (3) Behavior change communication (BCC); (4) Surveillance, monitoring and evaluation; and (5) Health systems strengthening. The consolidated grant structure mirrors the Plan s main strategies. There are four specific objectives as per the new draft strategic plan whose aim is to reduce malaria transmission through effective implementation of IMVC: To achieve and maintain universal access to LLINs in order to have at least 80% appropriate use by 2020. To consolidate and expand the scope of IRS intervention to protect at least 85% of the population living in selected areas using evidence - based criteria. Scale-up larval source management interventions in selected urban areas where breeding sites are few, fixed, and findable by 2020. Promote effective environmental management for malaria control amongst at least 80% of communities through local government authorities in all districts. LLIN Strategy The objective of the LLIN Strategic Plan is to achieve and maintain universal access to LLINs in order to have at least 80% appropriate use in the entire population. In line with RBM recommendations, the Ministry of Health and Social Welfare (MoSW) through the NMCP has developed and implemented both a combination of Catch Up (mass campaign) and well as Keep Up (continuous distribution) strategies. The current Global Fund investments, together with other partners, notably PMI and DFID, will address the four objectives of the draft National Strategic Plan, namely: Implement mass LLIN replacement campaign to maintain the universal coverage Implement keep up mechanisms to maintain high access to LLINs: the Tanzania National Voucher Scheme and the School Net Program (currently being piloted) - funded by PMI & DFID Re-establish a viable commercial market for LLINs in Tanzania; and Promote appropriate use of LLINs through BCC Keep Up Strategy (Continuous Distribution Mechanisms) The MoHSW initiated a broad consultative process in 2011 to define future continuous or Keep-Up distribution mechanisms. A wide range of distribution options were mathematically modeled and costed. Based on the review, a combination approach of the existing Tanzania National Voucher Scheme (TNVS) and a school-based net distribution program was assessed as most efficient and cost-effective continuous distribution strategy for Mainland Tanzania. The MoHSW is currently piloting the School Net Program (SNP) in three regions of Lindi, Mtwara and Ruvuma in the country s Southern Zone (population of about 3.5 million, i.e. 8% of the total population of 43.6 million). All school children in alternate classes are given a free LLIN annually for distribution to their households so that a child will bring home a new net to his or her household every second year. An evaluation of the pilot SNP will be completed by December 2013 and will inform the development of a national program. The evaluation will assess whether the Keep-Up Strategy can maintain the universal coverage; whether the schools as distribution points are successful in reaching households; whether the nets are being used by those 8

individuals that need them (issue of usage and redistribution); and if the modeling in terms of new nets needed is accurate. The cost involved in rolling out this strategy will be primarily covered by PMI and DFID in the three regions that will not be covered under the mass campaign. Tanzania Universal Mass Campaigns Background: Two mass LLIN campaigns were implemented between 2009 and 2011 during which a total of 26 million LLINs were distributed free of charge to the end users. The two campaigns were the most successful and largest distributions of LLINs ever, resulting in Tanzania being one of the first African countries to achieve universal household ownership of at least one LLIN amongst all segments of the population. The 8.7 million LLINs distributed during the under-five campaign are now older than three years. Most of the 17.6 million LLINs distributed in 2010/2011 during the universal coverage campaign (UCC) will be over three years old by 2014. The table below shows details regarding the two mass campaigns in Tanzania (2009-2011): Proportion Intervention Total LLINs Total Cost Paid by GF paid by Global Fund Global Fund Total Nets U5CC 8,753,438 $65,090,669 $26,774,269 41% 3,600,622 UCC 17,617,891 $93,643,633 $89,995,133 96% 16,931,471 Total 26,371,329 $158,734,302 $116,769,402 20,532,093 According to field studies, the median lifetime of a net is approximately three years, which means that at least 50% of the nets will be worn out by the third year. Figure 3 below shows the current age of the nets issued during the two mass campaigns, ranked in order of age since the last campaign (UCC). The 8.7 million LLINs distributed during the under-five campaign are now older than three years. Most of the 17.6 million LLINs distributed in 2010/2011 during the universal coverage campaign will be over three years old by 2014 (June 2013 data). Figure 3: Age of nets distributed during the last 2 campaigns There is therefore a critical need for replacement of these nets since a mass replacement campaign in the remaining regions with the oldest nets ensures high coverage by mid to late 2014, when LLIN coverage will likely have dropped below the 60% threshold due to decay of the previous campaign nets. The mass campaign strategy is based on the RBM quantification calculation model of 1.8 nets per every two people, to accommodate for the fact that households have uneven numbers of inhabitants. Households with three inhabitants, for example, will need to receive two nets. Nets will therefore be allocated by providing one net for every two people in households with even numbers, plus one additional net in households with uneven numbers. 9

Proposed LLIN Replacement Approach The following combination approach to regularly replace LLIN country wide is proposed: Continue the School Net Program (SNP) pilot in a part of the country (three regions in the Southern Zone) funded by PMI and DFID. Initiate the interim mass LLIN replacement campaign in the remainder of the country with the oldest nets (70% - 22 regions) funded by the Global Fund, prior to national scale up of the SNP. Continue the implementation of the TNVS at least until April 2015. In the absence of continued funding thereafter, develop an alternative ANC-based mechanism to cover the biologically vulnerable groups in the SNP regions to be funded by DFID. According to the TNCM, the advantage of the combination approach is to make optimum use of the comparative advantages of all partners; PMI providing the contracting mechanisms in a much shorter time than would be possible using the Global Funds investments, while the Global Fund can procure LLINs faster and at a lower price through the Voluntary Pooled Procurement (VPP) mechanism. Overall coordination, governance and supervision of the mass campaign as well as the advocacy and training will be done by the MoHSW and the Local Government Authorities. The campaign logistics, supply chain management component and the BCC campaigns will be outsourced to contractors. Summary of LLIN Commodity Needs According to the TNCM request, the US$ 114 million available through the interim NFM funding will be sufficient to cover procurement of approximately 18.9 million LLINs using the provided LLIN specifications. The budget also includes all the costs related to planning, advocacy and training, logistics and supply chain management, registration of households, distribution to village level, issuing of LLINs to beneficiaries, supervision, M&E and reporting. Costs for the BCC component will be covered from the consolidated malaria grant savings. The initial calculation of the interim funding envelope likely underestimated the quantity of LLINs needed as well as the full extent of the costs of auxiliary components to implement a mass campaign. As a result, the envelope is insufficient to cover the entire LLIN mass campaign requirement unless further savings are found either from adjusted LLIN specifications and carefully planned timing with VPP, or from other budget allocations within the consolidated grant. During the country dialogue process, it was namely agreed that the Global Fund investments will be channeled mainly to procuring LLINs through VPP mechanism for the mass campaign in the 22 regions. 3.2: Programmatic Gap Table Insert the programmatic gap table from the following hyperlink INTERVENTION Tanz. National Voucher Scheme LLINS NEEDED ANNUALLY LLINS needed 2014 GFATM PMI DFID TOTAL LLIN GAP 1,500,000 1,500,000 0 0 1,500,000 1,500,000 0 School Net Programme 510,000 510,000 0 510,000 0 510,000 0 Mass Replacement 22,284,976 18,996,595 2,035,169 0 21,031,764 1,253,212 Campaign TOTAL LLINs 24,294,976 18,996,595 2,545,169 1,500,000 23,041,764 1,253,212 The total number of LLINs required in the three year grant period (July 2013 June 2016) for the three different LLIN distribution mechanisms is approximately 27.5 Million. The Global Fund interim funding is sufficient to cover approximately 69% of this amount in addition to PMI's contribution of 2,035,169 LLINs to the mass campaign in 2014. As seen from the above table, there is a remaining gap of 1.2 million net (approx. US$ 7 million) to achieve universal campaign coverage in 22 regions of Tanzania. 10

Estimated unit cost per net delivered to service delivery point is US$ 5.57. The LLIN dimensions used for the 2011 campaign of 120 cm (width) x 180 cm (length) x 210 cm (height) were regarded as being to0 small. According to the recent THMIS survey, this resulted in about 2.5% of those who had nets not using them. Consequently, the TNCM has requested to use LLINs with dimensions 160 cm (width) x 190 cm (length) x 210 cm (height) for the next campaign. While the change in width and length may not have significant cost implications, the use of 210 cm height implies about 16% higher cost (i.e. approx. $17 million on forecasted quantity of LLINs for the campaign of 22,284,976) as compared to a more commonly used height of 180cm. This cost saving measure, if agreed, can be used to fill the 1,253,212 LLIN gap for the mass campaign. The PR s was requested to consider adjusting the height to 180 cm to ensure that universal coverage is achieved but has so far insisted on the 210 cm height on grounds that the current size is in line with the Tanzania Bureau of Standards Specifications for LLINs and registered with the Tanzania Pesticide Research Institute. 3.3: Funding Gap Analysis and Counterpart financing Resources available for the LLIN Strategy are shown in the table below: BETWEEN July 2013 - June 2016 FUNDING SOURCE INTERVENTIONS GoT GFATM PMI DFID SDC TOTAL % LLINs $0 $114,000,000 $25,000,000 $15,720,000 $0 $154,720,000 80% IRS $0 $0 $22,685,000 $0 $0 $22,685,000 12% Larviciding $10,930,000 $0 $0 $0 $0 $10,930,000 6% Technical Assistance $0 $0 $0 $6,000,000 $6,000,000 3% TOTAL $10,930,000 $114,000,000 $47,685,000 $15,720,000 $6,000,000 $194,335,000 100% The table shows that about 70% of fund sources are from the Global Fund, with DFID and PMI being the major contributors after GF covering about 25% and SDC the remaining amounts. The contribution of the Government of Tanzania is mainly towards larviciding interventions. Funding Landscape Chart showing Number of LLINs per Donor 2014 DFID, 1,500,000 LLIN GAP, 1,253,212 PMI, 2,545,169 GFATM, 18,996,595 11

Chart showing funding contributions per donor and LLIN gap 2014 It is also recommended that the country seeks other sources of funds including the Government of Tanzania, other development partners to fill in the gap of US$ 7 million or endeavor to access news funds as soon as possible as a standard applicant for the NFM after the envelope is known for Tanzania mid-2014. 4: Funding Recommendation and Budget Analysis Summary Budget Recommendation and Incremental Amount Year after cut-off date Year 1 Year 2 Year 3 Total Consolidated Grant Total Budget 145,506,422 51,597,207 27,665,206 224,768,836 Budget Recommended by the Secretariat PR 145,506,422 51,597,207 27,665,206 224,768,836 Total Budget Recommended 145,506,422 51,597,207 27,665,206 224,768,836 - Undisbursed amount at cut-off date - Cash at cut-off date RECOMMENDED INCREMENTAL AMOUNT 114,000,000 % of adjusted TRP clarified amount (cannot exceed 100% of adjusted TRP clarified amount) 100% 12

The full incremental amount of US$ 114,000,000 is recommended to fund the mass campaign. The total request made for consolidated grant is US$ 224,768,836 which is sufficient to fund the procurement of 18,996,595 LLINs as per the PSM plan. In view of the remaining LLIN gap (1,253,212 LLINs or approx. US$ 7 million) the full amount of US$ 114 million is required while further savings are sought to reduce/cover the present gap, as detailed above. The funding from the interim grant provides an opportunity to sustain the gains made by the National Malaria Control Program in Mainland Tanzania in the fight against malaria. Eighty one percent of the amount requested will finance the procurement of LLINs, medicines and the related PSM costs. Consolidated budget breakdown per Micro-Category, Objective and Service Delivery Area: Macro- Category Obj. Service Delivery Area Year 1 Year 2 Year 3 Total % Treatment 1 Supportive Environment: Diagnosis 5,868,134 8,364,704 7,092,489 21,325,327 9% Treatment 1 Prompt and effective malaria treatment 19,713,419 24,879,163 12,317,412 56,909,993 25% Treatment 1 Treatment of severe malaria 2,113,760 3,120,789 1,633,590 6,868,139 3% Prevention 2 Prevention: Insecticide treated nets 105,510,927 6,273,309 0 111,784,236 50% Prevention 2 Supportive Environment: Coordination and 132,244 137,842 26,619 296,704 0% partnership development Prevention 2 HSS: Information systems and operational research 314,600 1,604,460 0 1,919,060 1% Prevention 2 Supportive environment: capacity building to 1,892,487 294,728 302,370 2,489,585 1% implement IMVC activities Prevention 2 Monitoring insecticide resistance 18,195 0 2,240 20,435 0% Prevention 2 Indoor residual spraying 0 0 0 0 Prevention 2 Vector Control: Larva source management 0 0 0 0 BCC 3 BCC: Mass media and targeted communication 2,779,686 2,804,458 2,005,691 7,589,836 3% BCC 3 BCC: Community outreach 1,579,401 232,875 237,532 2,049,808 1% BCC BCC: Community 3 sensitization 947,509 816,729 665,117 2,429,355 1% M&E 4 Information system and operational research 1,892,958 508,967 1,086,805 3,488,730 2% M&E 4 Monitoring antimalaria drug resistance 116,047 137,075 139,754 392,876 0% Supportive Environment: Supportive 5 Coordination and environment partnership development 2,627,055 2,422,109 2,155,587 7,204,751 3% TOTAL 145,506,422 51,597,207 27,665,206 224,768,836 100% 5: Further contextual Information The following management actions are proposed in addition to the ongoing risk mitigation measures that are ongoing, as approved by ORC (malaria QUART): Mass campaign storage capacities: identification and assessment of warehouses to be used for the interim storage of LLINs at the MSD to ensure that there are adequate conditions to store LLINs as well as adequate security measures in place to safeguard the assets. The Secertariat to monitor the implementation of the electronic Logistics Management Information System (elmis) which is planned to be fully functional by December 2013. 13

ANNEX 1: PERFORMANCE BY HOST GRANT TNZ-M-MOFEA Performance Rating to cut-off date: 30 June 2012 PR : Ministry of Finance of Tanzania Apr 1 2011 - Dec 31 2011 Jan 1 2012 - Jun 30 2012 B2 B1 Cumulative Indicator Rating at cut-off date: 30 June 2012 Phase Start Date : 01-Apr-2011 Phase Start Date : 30-Jun-2013 Rated Start Date : 01-Apr-2011 Rated End Date : 30-Jun-2012 TNZ-M-MOFEA Service Delivery Area Indicator Is Number Is Top 10 Training Indicator Rated Target Rated Result Percentage 1.1 Yes Number of patients with suspected malaria receiving ACT treatment according to national policy through the public sector 20229578.600 17,312,794 86% Treatment: Prompt, effective antimalarial treatment 1.2 Yes 1.3 Yes Number of people with suspected malaria receiving treatment with ACTs through the private sector Number of children under 5 with suspected malaria receiving treatment with ACT through the private sector. 10242440 7,478,136 73% 5121220 1,378,684 27% 1.4 Health Facility with no Reported stockouts of national recommended antimalarial drugs lasting more than one week at any time during the past three months. N: 4,450 D: 5,000 P: 89 % N: 4,000 D: 5,000 P: 80 % 90% 1.5 Yes Number of Rapid diagnostic tests performed by public health facilities 20757600 4,824,377 23% Treatment: Diagnosis 1.6 Number and percentage of malaria cases that are laboratory confirmed (microscopy and RDTs) in public health facilities. N: D: P: 80 % N: D: P: 121 % 120% 1.7 Slide positivity rate in public health facilities. 1.8 Proportion of suspected malaria cases seen/attended by health workers at health facilities examined by either microscopy or RDTs. 14

1.9 Number of new accredited drug dispensing outlets (ADDO) out of the total targeted DLDBs (Duka La Dawa Baridi) 9500 4145 44% Prevention: Behavioral Change Communication - Community Outreach 2.1 2.2 2.3 Yes Proportion of caretakers of children under five years of age with knowledge of how to access ACTs Number of studies conducted and report produced Number of children receiving treatment for severe malaria at public health facilities according to national policy N: D: P: 75 % 2 317601 290,638 92% Training Indicator Rating N/A Average Performance on Top 10 60% Top 10 Indicator Rating B1 Average Performance All Indicators 69% All indicators Rating Number of TOP TEN Indicators with B2 or C Rating Renewals Indicator Rating B1 2 B1 Risk Heat Map 15