Ghana’s success in the Global Fund’s Differentiated Service Delivery Strategic Initiative

4. FROM THE FIELD
31 Aug 2022
What other countries can learn from Ghana’s achievements

Ghana is a lower middle-income country in West Africa with a population of 32 million people and a national HIV prevalence of 1.7%. There is significant variation in HIV prevalence across different geographical regions of the country and the different population groups, with key populations (KP) disproportionately affected. Under NFM3, the Global Fund included Ghana among the 10 countries to benefit from the HIV Differentiated Service Delivery Strategic Initiative (DSD SI).

The DSD SI had a late start due to COVID-19

In GFO 393 in February 2021, the Global Fund Observer announced the launch of one of the Global Fund’s 19 Strategic Initiatives (Global Fund Launches Its Differentiated Service Delivery Strategic Initiative). The 19 workstreams under Global Fund Strategic Initiatives total $343 million in the 2020-2022 allocation period. Strategic Initiatives are one of three modalities for funding catalytic investments. Catalytic investment priorities are defined by the Global Fund as being a portion of available funding that has been set aside for programs and activities that are essential to achieve the aims of the Global Fund Strategy and partner plans, but not adequately provided through country allocations alone. They support the success of country allocations but cannot be funded at the country level due to their cross-cutting or off-cycle nature. However, they are vital to ensure country allocations deliver according to the Global Fund Strategy. The other two modalities are multi-country approaches and matching funds.  Matching funds are designed to inspire innovation and ambitious evidence-based programming approaches to maximize impact in specific strategic priority areas.

Although launched late due to the pandemic, the countries moved quickly. In GFO 413 in June this year, the GFO reported on the preliminary promising findings in four countries (The Global Fund’s Differentiated HIV Service Delivery Strategic Initiative Shows Encouraging Results). As a result of these early successes, the Global Fund’s Grants Approval Committee allocated an extra $2.4 million for eight more countries.

Ghana was the first of the countries to show early promise

At the launch of the DSD SI in Accra in September 2021, there was optimism among in-country stakeholders that the new funding would catalyze the country’s early efforts to differentiate and tailor specific HIV services across different regions and population groups.

The DSD SI was anticipated to be a “game-changer” in Ghana’s HIV response, according to in-country partner the World Health Organization (WHO). It makes available essential technical assistance for the scale-up of differentiated HIV Testing Services (dHTS), differentiated HIV treatment (dART), and an advanced HIV disease (AHD) care package. Under the leadership of the National AIDS Control Programme (NACP) in partnership with the West African Program to Combat AIDS and STI (WAPCAS) and Christian Health Association of Ghana (CHAG) technical assistance is provided by JHPIEGO, SH:24 and EQUIP HEALTH Ghana under the technical coordination of WHO. Some of the activities to be implemented include the introduction of a virtual platform for HIV self-testing (HIVST), pre-exposure prophylaxis (PrEP), and community DSD approaches including community antiretroviral (ARV) refill.

“Overall, what we are trying to do is to help position Ghana on the trajectory to maximize its outreach. What we need to do is to differentiate the service delivery in order to find those that are harder to reach and make sure we’re going the final mile and including all in accessing services”.

Nicole Delaney, Global Fund Portfolio Manager for Ghana

 

By June 2022, Ghana had made the most progress among the 10 DSD SI countries in implementing the SI’s activities. Ghana managed to get this far through a combination of pre-existing factors (it already had DSD policies in place) and speedy adaptations (the Government was quick to mobilize, coordinate and collaborate with key stakeholders). These enabling and facilitating factors are not unique to Ghana, and other countries can apply them to accelerate progress of implementation of both their main grants and catalytic investments.

Let’s take a closer look at each of these factors

Ghana already had DSD policies and guidelines in place, developed as early as 2017. WHO and other partners had been working with the NACP from as early as 2017 to develop, refine and roll out the national guidelines for differentiated HIV testing, care and treatment. The same thinking on DSD interventions had gone into the Global Fund NFM3 HIV main grant. When Ghana was able to avail itself of the Global Fund DSD SI support, the NACP and other national stakeholders were able to build on the materials and principles of pre-existing DSD interventions.

Ghana has strong in-country coordination, mobilization and stakeholder engagement strategies that are jointly led by the WHO country office and NACP. The Technical Working Group (TWG) that developed the initial DSD guidelines was reconvened to support the seamless introduction, launch, start-up, implementation and periodical review of the DSD SI activities. Members of the TWG include NACP, the US President’s Emergency Fund for AIDS Relief (PEPFAR), the Joint United Programme on HIV/AIDS (UNAIDS), WHO, academic institutions, local organizations (some of whom are now Global Fund Principal Recipients [PRs]) and representatives of civil society organizations (CSOs). The early relationships and camaraderie developed during the DSD TWG period have been extended into supporting DSD SI activities.

Early clarity of roles and responsibilities among the different stakeholders prevented conflicts and inertia. The DSD SI came with technical assistance (TA) providers who were different from the known PRs for the Global Fund’s grants. This shift in the implementation modality for Global Fund grants had the potential to cause confusion and duplication of efforts by PRs and TA providers, despite both pursuing similar objectives. In Ghana, the DSD coordination team (led by NACP and WHO) was able to convene the different stakeholders early on and clarify roles and responsibilities. This was done in close consultation with the Global Fund Ghana Country Team in Geneva and ensured that any grey areas were quickly clarified, and each stakeholder was able to get on with activity planning and implementation.

Regularity of performance review meetings and openness to agility and adaptations ensured lessons learned are moved forwards. The NACP and WHO country office convene a monthly meeting to specifically discuss DSD implementation in the country. The regular meetings not only bring together DSD SI stakeholders such as the Country Coordinating Mechanism (CCM) but also PEPFAR, since the United States Agency for International Development (USAID) is supporting implementation of HIV activities not covered by the Global Fund in the rest of the country. These meetings serve as a platform for regularly monitoring progress of the DSD SI work plan, identifying and addressing issues as they emerge, and facilitating knowledge-sharing among DSD and broader HIV stakeholders in the country

There’s general consensus among different stakeholders that the DSD SI has significantly facilitated adoption and scale up of DSD activities throughout the country. For example: (a) Jhpiego’s support in revising and updating DSD guidelines ensured that the scale up facilities are using the updated guidelines; (b) EQUIP Health Ghana’s activities in training health facility teams to adhere to quality of care standards even as they embraced DSD ensured that the quality of testing and treatment was consistent with national standards; and (c) SH:24’s efforts to develop a virtual platform will ease access to HIV testing services for population groups previously not reached by traditional approaches.

Some quotes from stakeholders
"We are happy with the support we are receiving from the TA providers, especially SH:24. We see a lot of promise in the virtual platform for reaching KPs as it directly complements what we are doing at WAPCAS. We hope to scale it up in NFM 4 [Global Fund's next grant cycle] as NACP is keen on having a virtual platform as a key intervention in improving access to HIV testing services".
Comfort Asamoah-Adu, Executive Director for WAPCAS, a Global Fund PR for KPs
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"It is important that the Global Fund engaged and consulted with national stakeholders in the procurement process for TA providers, even when they are following an open bidding/solicitation process. The consultations help to ensure that the selected service providers are credible, have country experience and context, and can leverage relationships to get work done faster."
Nii Akwei Addo - Executive Director for EQUIP Health Ghana
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"There is proper alignment and a close relationship between WHO Country Office and NACP, that's partly why Ghana is doing very well on DSD SI."
Stephen Ayisi-Addo, NACP Program Manager

 

What we are learning from Ghana is that external funding (from the Global Fund or elsewhere) is always most impactful if the existing infrastructure is adequately prepared prior to receiving the funding, and in-country structures are strong enough to provide guidance, coordinate stakeholders and monitor progress of implementation. These lessons are not only applicable to the Global Fund’s HIV program in Ghana, but can also be transferred to other grants, other financing institutions and other countries. 

What we have seen with Ghana is how important it is for efforts to be wholly country-owned and driven. It is critical to adequately invest in the people, not only those receiving care, but also the locals leading, coordinating, implementing, monitoring and supporting the work in-country. Strengthening service delivery platforms in an environment where you have strengthened institutions, and mutual trust and respect in the partnership, is a recipe for success that we can replicate elsewhere”.

Obinna Onyekwena, Global Fund HIV Advisor

 

For more information, look at WHO’s photobook of the launch of the Ghana DSD SI.


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