How will the Global Fund move from one-off support to sustainable health system strengthening?
At the end of a funding cycle (2017-2019) and a year of review of applications for the 2020-2022 cycle (NFM3), the Global Fund has published several documents related to investments made to strengthen the health system. The analysis conducted by the Technical Evaluation Reference Group (TERG) synthesizes the various analyses produced over the past two years: the country evaluations, the mid-term evaluation of the 2017-2022 Strategy, the Technical Review Panel (TRP) reports following the 2017-2019 and 2020-2022 rounds, and the Office of the Inspector General (OIG) report. In addition, the TERG consulted and held group discussions with additional TRP members, who supplemented the review with information on the impact of COVID-19 on public health programs.
The Technical Evaluation Reference Group is an independent evaluation advisory group, reporting to the Global Fund Board through its Strategy Committee, to ensure an independent assessment of the Global Fund's business model, investments and impact. It provides independent advice on monitoring and evaluation issues.
Highlights of the TRP Advisory Report
The TERG report begins with an analysis of funding provided to date for health systems strengthening. Rather than being a long-term investment to install the systems necessary for the proper functioning of the various health programmes (health information systems, health product management systems, human resource management systems), the grants are designed to fill gaps. In fact, the financing granted within the framework of strengthening resilient and sustainable systems for health (RSSH) is one-off, designed for a short period of time that respects the three-year grant period. In the majority of cases, financing is used to facilitate the implementation of disease grants: this is typically the case for bonuses paid to health staff, particularly those in disease control programs, which are classified as human resource strengthening even though they fill the gap of no or very low salaries. This is also the case for laboratories’ strengthening which is aimed above all at structures that allow the analysis of samples taken for HIV and viral load testing or for tuberculosis (TB) screening.
As noted by the TRP and TERG, opportunities to integrate other diseases and maximize investments for broader and sustained benefit than that achieved by disease programs are therefore regularly missed. This is especially true when activities dedicated to system strengthening are scattered across different disease funding applications (malaria, HIV and TB).
The TRP concludes that this approach is detrimental to the achievement of the countries' objectives, reflected in the national strategies translated into national health development plans. As a result, it is unclear what contribution health system strengthening (HSS) funding makes to the implementation of national health strategies and to the achievement of universal health coverage (UHC), the basis of the Sustainable Development Goals (SDGs). Finally, the TERG regrets the compartmentalized approach of the other global health donors and the absence of effective mechanisms for consultation and dialogue which would lead to better aligned investments between donors and complementary donors.
The second element to consider, which is a result of the first, concerns the inadequacy of the Global Fund's management model for strengthening RSSH. Indeed, the funding cycle lasts only three years, which is still very short compared to the RSSH timeframe in the countries, which is reflected in the health development plans that usually cover five and sometimes even ten years. However, the tools proposed by the Global Fund, which the TERG notes are not widely used or understood by those involved in planning funding requests, are not well adapted to RSSH. Finally, the TRP notes that a lack of clarity in the definition of RSSH, which has still not been agreed upon by the Global Fund Secretariat, Global Fund partners and recipient countries, has also contributed to the confusion.
The third point raised by the report concerns the measurement of the impact of RSSH funding: indeed, data collection and measurement tools have been largely non-existent, preventing a detailed and evidence-based analysis of the results of NFM1 and NFM2.
TRP and TERG recommendations for the future
The strategic vision and its practical translation
The TERG has seized the opportunity of this report to make recommendations for HSS investments. It advocates that the Secretariat take a broader approach to public health programs, health systems, and preparedness for future epidemic emergencies to ensure results that contribute to achieving UHC. Future RSSH investments should, the TRP says, help support health services that are as integrated as possible, functional, and constitute longer-term commitments and investments. This also addresses the need to move from short-term, input-oriented ‘support’ to longer-term ‘strengthening’ of health systems. The paper argues that the Global Fund should also take a ‘holistic government approach to RSSH and the World Health Organization (WHO)’ and strengthen partnerships, acknowledging that multi-sectoral coordination is essential to control epidemics and ensure health system sustainability.
Mobilizing domestic resources to ensure the sustainability of investments
The TERG report emphasizes the need to ensure sustainable funding and encourage better mobilization of domestic resources, and support the development of sustainability plans and in-country emergency response planning. The paper recommends that the Global Fund align HSS investments with the evolving goal of pandemic preparedness and response, particularly in the areas of surveillance, supply chain and human resources and response coordination.
In addition, RSSH investments would benefit from better performance monitoring and greater attention to human rights and communities, including community systems strengthening. This also needs to be planned strategically and sustainably.
Third, the paper suggests updating documentation and procedures before the 2023-2025 allocation period. This includes promoting a better understanding of HSS and its application, calling for a unified investment approach and integrated plans for HSS investments. It also recommends that the Global Fund Secretariat improve compliance with RSSH guidelines by introducing mandatory requirements.
The Secretariat's responses to the TERG report
The Secretariat's responses suggest that the Secretariat has anticipated the recommendations concerning the formalization of the broader HSS vision. It is counting on the new Strategy and its narrative to clarify the Global Fund's positioning on this subject, in particular on the relationship between HSS, UHC and preparedness for epidemic resurgence, through a patient-centred vision.
In addition, the Secretariat is relying heavily on the activities that will be implemented under the Service Delivery Strategic Initiative coordinated by the Secretariat’s RSSH Team. This initiative has six different axes and should make it possible to accelerate performance on subjects as complex as the management of human resources for health, the delivery of accessible and quality services, collaboration with the private sector or community-based monitoring.
Finally, the Secretariat refers to the performance framework that accompanies funding applications, and the collaborative effort between the HSS Division and staff in the Monitoring and Evaluation Unit.
Comments and additions
The TERG report endorses the experiences of the stakeholders who worked on the current round of grants in 2020, and it is gratifying to see that the report’s evidence has triggered a much-needed debate about what the Global Fund seeks to achieve through its RSSH investments.
Discussions began almost 18 months ago with the development of the next Strategy, and often divergent positions have emerged regarding RSSH. This divisive issue has split constituencies, to the point that the African representatives on the Executive Board, who are advocating for a greater emphasis on HSS in the Fund's new Strategy, abstained from voting during the special session of 22 July.
The debate that started at the October committees in 2020 will continue at next week’s Board meeting and it is likely that the question of the allocation formula and the design of the grants (and the split between diseases and RSSH) will be discussed, as it was in 2016. One can only hope that the TERG report, which synthesizes many documents that all point in the same direction, will inspire constituencies and the Secretariat to make the right decision. It calls for looking at HSS differently, as a component in its own right, with specific, long-term objectives that contribute more clearly and concretely to the SDGs and UHC, while also assuming the role that the Global Fund must play in preparing for epidemic emergencies.
If you want to succeed, you have to give yourself the means to do so?
Many of the responses provided by the Secretariat to the TERG report seem anachronistic as the tools created for NFM3 had already attempted to address the problems identified by the TRP in late 2019. That said, these tools have created other difficulties, to which the Secretariat only responds with a promise to further evolve the methodology for developing HSS applications before 2023. Similarly, and most regrettably in our view, the Secretariat is focusing solely on process, oversimplifying the problem posed by the TERG and the solution envisaged, rather than looking at its operational translation.
For example, in response to the criticism that RSSH funds are being used to fill gaps to facilitate disease grant implementation, the Secretariat says that procedures and technical notes for country actors have been produced to address this difficulty. As if a guidance note alone could change the practice of looking for the most immediate result that will lead to better disease performance!
Similarly, regarding the question of the link between Global Fund investments and the achievement of UHC, the Secretariat responded with technical notes that are supposed to provide guidance: while the issues of health financing, social protection for patients, and UHC implementation is complex, requiring a long-term vision and an effort by donors to collectively support these systems under construction.
As another example, the TERG recommends that ‘stand-alone’ disease-specific RSSH grants should be more common. The Secretariat's response is again based on a process of ‘informing countries’ that this possibility exists. Here again, we know how important it is to ensure a Principal Recipient (PR) has the capacity to manage RSSH activities, and that this has nothing to do with the level of ‘information’ available but rather with a substantive debate on the place of the system in the grant architecture and a high-level political buy-in that will result in a specific grant managed by the Ministry of Health (MOH).
The disturbing lack of operational responses
The absence of operational recommendations is surprising and somewhat dismaying, given that the grants began in 2021 and continue until December 2023. Indeed, we know that the activities to which the report refers will be difficult to carry out, disappointing in their impact, and difficult to measure in relation to the objectives of national health development plans. How then can we explain the absence of specific recommendations aimed at anticipating the bottlenecks usually encountered in the implementation of activities to strengthen the health system? This is surprising, given that the TERG repeats the conclusions of the prospective country evaluations (PCE), which noted that the sums unspent in the first few months of RSSH activities disappeared during reprogramming in favour of other activities that are more easily disbursed. Instead of analyzing and responding to the challenges, implementing agencies decided to abandon the original planning altogether, thus reducing the share of RSSH activities in the evaluated countries from 11% to 9%.
The tools for monitoring activities are only mentioned in the implementation framework, a subject that is brushed aside in the Secretariat’s response. The Secretariat considers that the progress made in refining the indicators will make it possible to measure the degree of the objectives’ achievement.
But no mention is made of the numerous bottlenecks related to the lack of HSS knowledge in the Country Coordinating Mechanisms (CCMs), the lack of coordination of the ‘RSSH’ PRs with the disease programmes and the Sub-Recipients, with the MOH’s central directorates and its regional branches, the slow progress in the punctuality and reliability of District Health Information Software (DHIS) 2 data feedback, and the transactional cost for PRs managing several HSS grants from different donors with varying implementation and technical and financial reporting requirements (such as annual audits specific to each donor and each grant). This ‘blind spot’ in the analysis is all the more surprising given that there are solutions which require little money (while Strategic Initiatives, Service Delivery Initiatives, additional posts and technical assistance are expensive).
There are good opportunities to maximize RSSH funding by December 2023: the additional COVID-19 Response Mechanism (C19RM) envelopes can complement NFM3 grant investments, and broaden the scope somewhat, as recommended by the TERG. Among the activities proposed in the C19RM modular framework, those related to emergency preparedness (for example, manuals, training, simulations) contribute to decentralizing and raising the bar for broader support to the system, so that it is resilient to shocks and prepared to manage epidemic resurgences. Another window of opportunity is the reprogramming that has already begun and will continue throughout the implementation cycle. It is possible, thanks to these unused funds, to review certain approaches in order to decompartmentalize them or to add activities that aim to assist implementation by supporting RSSH funds’ management, assisting PRs to identify and resolve bottlenecks and coordinate with other directorates and other RSSH donors. However, this requires a clear vision of the challenges, an ambition to make RSSH a priority, and clear data on the expected impact in order to defend these types of reprogramming. In the TERG's opinion, the opposite is true, with RSSH funds dwindling as unspent funds are reused for other activities, reinforced by portfolio optimizations that benefit system strengthening activities much less than diseases.
Let’s hope that these issues will be addressed, so that the large envelopes invested in RSSH for the current cycle are optimized in a context of competition for health emergencies and that the Secretariat and country actors will not put all their efforts into the funding request process, but into grants implementation, which is key to achieving the expected results.