The Technical Review Panel notes some improvements in Global Fund funding requests

6. NEWS
31 Aug 2022
But prioritization is weak and gender equality and human rights still fare badly

In July, the Global Fund published the 2020-2022 Technical Review Panel (TRP) Observations Report. This article looks at the TRP’s observations by Strategy area and the implications of the findings for the upcoming new grant cycle starting in the autumn.

Introduction

During the 2020-2022 allocation period, the TRP recommended 195 funding requests (FRs) to proceed to grant-making: a record-breaking allocation of $12.618 billion. Another 12 (6% of the total) were revised and resent for approval. There were $6 billion Prioritized Above Allocation Requests (PAAR), resulting in a total of $5.7 billion added to the Register of Unfunded Quality Demand. Furthermore, the TRP reviewed catalytic funding investments ($878.5 million): 15 Strategic Initiatives developed by the Secretariat, six multi-country requests, and Matching Funds proposed alongside 53 FRs.

 

Figure 1. Funding request review and recommendation

The TRP commended applicants for their “strong funding requests which described programs that were strategically focused, technically sound and poised to deliver value for money and impact towards ending AIDS, tuberculosis (TB) and malaria”.

The TRP made a number of comments to assist applicants and their technical partners in preparing future FRs.

Focus

The TRP felt that most applicants had successfully aligned their FRs with national disease and health sector strategic plans and built on the challenges, results and impacts of national programs, and/or previous Global Fund investments.

However, the TRP raised the issue of insufficient prioritization. Many FRs included a large number of modules and interventions whose investments were not sufficiently ranked according to the highest impact interventions within the specific country context, with regard to epidemiology, the available resources, and cross-cutting challenges.

Take-home message 1: Improve prioritization

  • Prioritize modules and interventions and define a tighter program focus using robust disaggregated data. Investments should focus on populations inadequately reached by prevention interventions and those populations that lack access to, and/or show lower retention in treatment and care services.
  • Prioritize interventions addressing related social determinants of health, including human rights and gender equality barriers and system weaknesses, as well as selecting investments to ensure value for money and sustainability.

 

Technically sound

The TRP found most FRs were based on high-quality data and described scientifically robust, evidence-based approaches, aligned with normative guidance and national guidelines.

Yet prioritization was still a recurring issue. The TRP found FRs that still failed to prioritize epidemiologically appropriate interventions to improve equitable access to prevention, diagnostics, care and treatment services among, and led by, key and vulnerable populations (KVPs). Moreover, such interventions were habitually relegated to the PAAR.

Take-home message 2: Maximize data use

  • Pay increased attention to emerging evidence-based innovations to improve the quality of people-centered services and programs.
  • Technical partners should support early adoption, scale-up, and equitable implementation of new normative guidance and guidelines and should facilitate access to better prices for new health products.

 

The TRP also commented on the need for better capacitated local expertise, trained through a systematically developed comprehensive capacity building strategy/plan.

 

Take-home message 3: Build national capacity

    • Build sustainable local capacity through comprehensive, rather than ad hoc, plans for technical assistance.
    • Use regional and local technical support providers, or providers from implementer countries, wherever possible, rather than costly international technical assistance.

 

Potential for impact

The TRP was encouraged to note investments in high-impact, cost-effective interventions, including efforts to deploy available new tools and innovations. However, prevention investments, especially for HIV and TB, were inadequate.

While 91% of FRs were good quality and strongly aligned with national priorities, applicants struggled with adequately responding to inequities. The TRP assessed FRs to be weakest at addressing gender equality and human rights, with only 55% addressing gender-related barriers to services and 62% focusing on human rights. The TRP was encouraged to see improvement in addressing human rights barriers compared to the last cycle; however, it worried that attention to gender equality remained weak and had not improved over time.

The TRP was also concerned that investments were overly focused on direct support instead of a catalytic use of Global Fund resources within the overarching funding landscape to improve disease programs while simultaneously strengthening health and community systems.

Take-home message 4: Address sustainability

Maximize impact by addressing sustainability: focus on the efficient use of Global Fund and other resources; integrate services; increase and sustain domestic resource mobilization; and use innovative mechanisms and co-financing arrangements.

 

HIV

HIV FRs presented strong testing and treatment programs, well-aligned with World Health Organization (WHO) guidance, and included innovations such as self-testing, multi-month dispensing and virtual consultations, often leveraging opportunities created by the COVID-19 pandemic. However, there were challenges reaching the “last mile” in countries close to 90-90-90/95-95-95 and reaching underserved populations, in particular men, children, and KVPs.

There was more focus on KVPs and adolescent girls and young women (AGYW) in the analysis behind FRs. However, many FRs did not consider all the KVPs identified in normative guidance. The TRP also observed insufficient attention to intersectionality and the connections between various KVPs. Few FRs disaggregated KVPs by gender, and those considering AGYW hardly ever paid attention to the overlaps between sub-groups of AGYW and KPs (e.g., those who are sex workers).

Although applicants have improved HIV prevention prioritization relevant to local contexts, KVP investments remained inadequate, especially for community- led interventions which tended to be relegated to the PAAR. Overall, there was only a modest increase in those investments in KVPs since the previous funding cycle.

Take-home message 5: Pay more attention to KVPs and AGYW

Prioritize sustained, optimal coverage of high impact interventions targeted to KVPs and AGYW. This includes greater investment to address human rights and gender-related barriers to achieve impact, including legislative barriers, such as criminalization.

 

The TRP saw promising examples of integration, in particular with reproductive, maternal, newborn, child and adolescent health programs, but still not enough focus on sexual and reproductive health and rights, even within prevention of mother -to-child transmission programs. Prevention and mitigation of sexual and gender-based violence was infrequently prioritized for funding.

The TRP noted some stronger approaches to address HIV/TB coinfection yet most FRs continued to present fragmented approaches to investing in HIV and TB prevention and treatment, and weak integration of HIV/TB services. While HIV KVPs were relatively well defined, they were insufficiently described for TB and very few programs adequately analyzed gender.

TB

Many TB programs maximized synergies with COVID-19 through bi-directional screenings, digital tools for treatment adherence, accelerating existing tools and innovations such as GeneXpert and computer-aided diagnosis, and training and deploying TB community members to also respond to COVID-19.

The TRP appreciated that most FRs contained a TB cascade analysis and gradual improvement of TB diagnostic and treatment services. While FRs showed increased prioritization of policies and guidance on TB prevention, the TRP was concerned that implementation of TB preventative treatment (TPT), especially shorter regimens, remained low.

Take-home message 6: Increase TB prevention activities and retain patients in care

  • Access more support to plan and implement interventions to prevent TB, and to diagnose and retain KVPs in treatment and care, using detailed situational and data-driven analysis.
  • Pay more attention to data and approaches for pediatric TB, including availability and use of pediatric TB treatment, healthcare worker training to identify pediatric TB, robust contact investigations that include children and widespread TPT adoption.

 

The TRP was concerned that relatively few civil society and community-led TB organizations were mentioned in the development of TB FRs and/or implementation. Community mobilization required more investment, with greater attention to community health workers (CHWs) for TB and community health activities.

Malaria

Malaria cases and deaths have remained high or significantly increased in many countries. The TRP said that sustained, optimal coverage of high impact interventions, such as appropriate vector control and universal access to diagnosis and treatment among most at-risk populations, should be prioritized before considering other interventions.

The TRP was pleased that many FRs used microstratification to inform interventions in high-burden, high-impact countries, through WHO and other technical partner support. However, FRs could be improved by using localized surveillance, monitoring and evaluation to guide the tailoring and targeting of malaria prevention and treatment interventions to maximize coverage and impact on burden reduction.

The TRP noted that some FRs also included solid analyses with disaggregated data based on national human rights and gender assessments. This was an increase on previous allocation cycles, but still not universal. The TRP encouraged countries to use the Malaria Matchbox Tool, and other tools, to capture and use disaggregated data for programming.

The TRP saw many good examples of CHWs as part of integrated community case management, yet there was inadequate harmonization and integration with CHWs focused on maternal, newborn and child health.

Maximizing people-centered, integrated systems for health to deliver impact, resilience and sustainability

Many FRs described community systems and efforts toward people-centered, integrated systems for health, yet disease-specific interventions, especially for KVPs, remained vertical with limited integration within systems for health. Stigma and discrimination in mainstream public health systems often create barriers for KVPs to access integrated services. Notwithstanding this, the TRP observed that FRs failed to consider a holistic approach to health, addressing wider issues such as co-morbidities and mental health.

Many FRs stated that they planned to address “quality”, but few invested in monitoring and measuring the “quality” of services provided.

Take-home message 7: Place greater emphasis on community-led monitoring

Invest in community-led monitoring as an important part of a quality assessment approach.

 

Community systems and responses were incorporated in many FRs, yet these investments were limited and overly focused on CHWs rather than the full scope of community infrastructure and services envisaged. CHWs are an essential health systems component – not solely related to community systems – yet the scale of investment in FRs was currently not commensurate with the level of ambition envisaged and certainly not for CHWs employed by community organizations, including services led by KVP peers.

The TRP was concerned that few FRs made adequate investments in the health policy and systems needs required to optimize CHW programming and align with WHO guidance.

Take-home message 8: Revisit investments in community systems

  • Pay less attention to CHWs and more to the broad gamut of community system infrastructure.
  • Develop longer term plans and execute viable sustainable financing pathways.

 

Take-home message 9: Invest more national and other resources in communities

  • Increase financing, from domestic sources as well as Global Fund investments, for comprehensive community systems, including for community-based organizations and service delivery led by KVPs and most affected communities, as well as for CHWs of all types.
  • Increase domestic health financing and strengthen public financial management systems.
  • Strengthen government leadership, working in partnership with relevant stakeholders, to design and operationalize policies and practices that will place people at the center of quality services.
  • Incorporate people-centered HIV, TB and malaria services into the essential healthcare service package under universal health care schemes, including through private sector participation.

 

Hints for new funding cycle applicants

The TRP also commented on how future FRs could contribute to the “mutually reinforcing contributory objectives” of the new Global Fund strategy.

Health systems

The TRP encouraged applicants to prioritize strengthening core health system functions, including procurement and supply chain management and the provision of essential health services, prior to investing in new technologies that often require extensive support before being fully integrated into health systems.

Maximizing the engagement and leadership of most affected communities to leave no one behind

While the TRP was pleased to see increased attention to the active engagement and leadership of communities in the development of FRs and national strategic plans, it noted this is still mostly focused on HIV. It wanted to see increased efforts to include and build effective community engagement and leadership in planning, implementation and monitoring of TB and malaria programs.

Few FRs were focused and structured to meet the holistic needs of affected communities, especially KVPs. The TRP encouraged integrated, complete services, in particular programs that have actively engaged communities, and programs led by people with lived experience of HIV, TB and malaria (HTM).

Sustainability plans should include public funding and contracting mechanisms (often known as “social contracting”) and co-financing for civil society and community-led advocacy, monitoring and other functions. All of these were critical for government accountability, political commitment and quality of services, especially in countries planning to transition from Global Fund support.

Maximizing health equity, gender equality and human rights

An increasing number of malaria FRs recognized socio-economic inequity makes people more vulnerable to severe cases of malaria, as well as the special vulnerabilities and barriers to accessing services for cross-border populations and migrants.

TB care and prevention among migrant, mobile, refugee and cross-border populations also received increased attention but differentiated approaches to reach identified populations were inadequate.

The TRP noted increasing commitment to address issues related to equity and equality in HTM programs, especially to meet KVPs’ specific needs. It also appreciated the increased use of globally recognized tools to assess human rights and gender-related barriers. Unfortunately, too frequently, interventions to address the issues were insufficient to meet need, were siloed, and often included in the PAAR.

Few gender assessments considered all genders. FRs rarely addressed the needs of transgender, non-binary and gender non-conforming people, and where they did, often their needs were still (inappropriately) combined with those of gay men and other men who have sex with men. In other FRs “gender” seemed to be interpreted as “women and girls” rather than, for example, considering the needs of men who are highly vulnerable to TB and designing programs to address their poor health seeking behavior.

The TRP were concerned that if gender assessments were conducted, they rarely translated into well-targeted services and interventions with targets to monitor outcomes. Too few FRs considered the wider determinants of poor health, including racial, indigenous and ethnic inequities in access to services.

Take home message 10: Data importance

  • Collect, update, analyze and use disaggregated data to identify intersectional gaps on a regular basis.
  • Consider socioeconomic status, age, gender, race, indigenous and ethnic background, education and other epidemiologically relevant demographics.
  • Use the resulting analysis to propose interventions with corresponding budgets.
  • Analyze and mitigate financial barriers to access, especially among economically disadvantaged populations, including removing user fees, or integrating HTM services in universal health coverage schemes, to achieve greater equity, mitigate poverty and improve access to services.

 

Mobilizing increased resources

The TRP was pleased to see data from funding landscape and gap analysis tables being used to direct funding and programming to critical areas. However, it was often challenging to detect the catalytic effect of Global Fund contributions and understand how Global Fund resources aligned with and complemented other sources of funding, domestic and external. In some cases, Global Fund financing was insufficiently aligned with other external and domestic resources.

Take-home message 11: Better reflect health expenditure data

  • Provide information on the overall funding of systems for health including main stakeholders, health financing analysis and reforms, and how Global Fund investments are integrated.
  • Provide information on overall health sector performance and efficiency, including health financing indicators, in performance frameworks.
  • Minimize spending on program management, while strengthening the capacities of systems for health to deliver quality services, including through harmonizing salaries and rationalizing the use and distribution of salary supplements.

 

Many FRs overemphasized commodities and short-term support for human resources, rather than investing in building longer-term sustainable processes, systems and policies, with a focus on efficiencies, integration, coherence and maintaining government expenditure on health.

 

Take-home message 12: Better use of co-financing mechanisms

  • Use innovative mechanisms and co-financing arrangements, aligned with the Sustainability, Transition and Co-financing Policy, to build better value for money.
  • Program Global Fund investments and domestic resources together, to complement each other and to ensure a focus on high impact, effective interventions.

 

The TRP noted some strong FRs that accelerated partnerships across sectors.

Take-home message 13:

  • Strengthen national leadership for inclusive multisectoral partnerships to support stronger, better integrated outcomes, and to strengthen private sector collaboration for service delivery, going beyond the provision of discounted health products.
  • Encourage strong domestic buy-in and an increased health budget for health financing reforms that address the entire health system.
  • Leverage external technical and financial support.

 

Pandemic preparedness and response (PPR)

The TRP appreciated the scale and speed of applicants’ responses to COVID-19 and the varied ways in which FRs reflected immediate and sustainable steps taken to mitigate the impact on HTM programs, build on experience (for example learning from TB contact tracing programs to set up contact tracing for COVID-19) and achieve quality improvement (for example, using digital adherence and multi-month prescribing)

Overall, the TRP observed that, in the context of COVID-19 in FRS, community systems strengthening, gender equality and human rights considerations were rarely included in PPR. This was most notable in the lack of attention to community sector responses and missed opportunities to engage KVPs and address their specific vulnerabilities and exclusions.

The TRP encouraged opportunities to take stock of HTM lessons learnt in order to avoid the trap of a disease-specific approach when designing and implementing PPR interventions, including investments through the Global Fund’s COVID-19 Response Mechanism (C19RM).

Take-home message 14: on PPR

  • Address broader societal and community impacts of novel pandemics and emergencies, to address human rights considerations and ensure that women, girls and KVPs have safe access to prevention, diagnosis and care.
  • Increase attention to multi-pathogen interventions, and take a more collaborative approach to health programs, health systems, and health sector development.

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