Global Fund’s efforts to improve service quality: successes and challenges
Service quality was one of the five strategic thematic areas that emerged from the work of the Office of the Inspector General (OIG) in 2016, as described in the OIG’s 2016 annual report. Another article in this issue provides a short summary of each theme. In this article, we provide more details on what the OIG said about service quality.
The OIG noted that a number of initiatives within the Global Fund Secretariat were successfully promoting service quality.
The introduction of a Program and Data Quality Strategy and new principles-based operational policy guidance is expected to help country teams in the Secretariat develop a more robust approach to assessing program and data quality risks. (See Operating Policy Note on Program and Data Quality in the Fund’s Operational Policy Manual; added on 13 July 2016.)
In 2016, the Secretariat also developed a framework related to “Data Use for Action and Improvement.” The framework is designed to evaluate different sources of data to improve value for money and quality of service delivery. In addition, health facility assessments are currently being piloted in a number of countries to provide better quality assurance over program and data risks.
The Secretariat’s Implementation Through Partnership (ITP) project has resulted in increasing technical cooperation between partners to ensure better quality of services. The ITP has helped transform the engagement with partners from just a general dialogue on collaboration to a more focused discussion on specific implementation challenges at the country level. It has enabled partners to have better visibility into each other’s priorities and focus areas. Finally, the ITP has helped improve accountability, with specific responsibilities assigned to different partners for carrying out distinct action items. (See GFO article.)
However, the OIG said, initiatives to improve service quality will take time to yield measurable impact at the country level. “In the meantime, as countries scale-up their coverage, the quality of services delivered is strained,” the OIG said. “Symptoms of this include decreased patient retention, non-compliance with Global Fund and national guidelines, and gaps in diagnosis.”
Decreased patient retention
“Service quality depends on sustainable health systems solutions, rather than quick fixes… It requires a significant shift in how the Global Fund measures performance.”
Several country audits in 2016 revealed that while the number of patients on treatment has increased, retaining them has become increasingly difficult. For example, the OIG said, in Zimbabwe, India and Mozambique, significant proportions of patients who have started antiretroviral treatment for HIV drop out or are lost after 12 months. For all three diseases, it said, low treatment adherence presents significant risks that massive investments in drugs and treatment may not yield the expected results in terms of disease prevalence. Low treatment adherence could also be a contributing factor to drug resistance.
Non-compliance with national and Global Fund guidelines
The OIG cited examples of non-compliance from three audits conducted in 2016. In Malawi, a low proportion of HIV-exposed infants and children were being tested in recommended timeframes. In India, there were multiple non-compliance problems in standards for TB care. The auditors also highlighted gaps in implementing a working pharmacovigilance system; testing delays; and a lack of preventive treatment for patients living with HIV who test negative for TB. In the DRC, contrary to both national and WHO guidelines, only 4% of patients received HIV testing and counselling in the two hospitals sampled by the OIG.
Gaps in diagnosis
In its Zimbabwe audit, the OIG noted that he effectiveness of the country’s diagnostic services was affected by the limited availability of machines. For example, equipment for screening TB in children was not available in over 50% of facilities visited. In Mozambique, the OIG said, although the number of diagnoses for the three diseases increased during the audit period, 34% of providers using microscopes and 20% using rapid diagnostic tests made inaccurate malaria diagnoses. In Malawi, 60% of patients treated for malaria at health facilities had not been tested, and suspected malaria cases were reported and treated through the country’s integrated community case management program without a confirmed diagnosis.
The OIG believes that the root causes of these symptoms stem from systemic challenges at the country level related to constraints in funding and in human resources.
In its concept notes submitted for the 2014-2016 allocation period, the OIG said, the DRC estimated that only 16% of the funds needed are available for HIV, 44% for TB, and 57% for malaria. The OIG’s Zimbabwe audit found that inadequate funding limited the scale-up of efforts to find active TB cases. In Mozambique, the OIG noted, existing Global Fund grants do not include funding for the supervision of laboratories that diagnose the three diseases.
Decreased patient retention
“As countries scale up their coverage, the quality of services is strained… Symptoms of this include decreased patient retention, non-compliance with guidelines, and gaps in diagnosis.”
With respect to human resources, the OIG noted that the World Health Statistics 2016 report, published by the World Health Organization (WHO), estimated that there was a global deficit of approximately 17.4 million health workers in 2013, with the worst affected areas being countries where the majority of Global Fund investments are made. The OIG said that its work in 2016 confirmed that a lack of trained staff contributed to service quality issues. For example, in Mozambique, as many as 65% of technical positions in the TB and HIV programs are vacant. In Zimbabwe, only 56% of the positions for primary counsellors for HIV had been filled at the time of the audit. The Zimbabwe audit also highlighted that only 16% of health workers had been trained on updated rapid HIV testing protocols.
“Service quality depends on sustainable health system solutions, rather than quick fixes,” the OIG said. “Service quality requires a significant shift in how the Global Fund measures performance.” In the current performance-based funding model, the OIG explained, the evaluation of program performance is mostly focused on output and coverage indicators. There are fewer program quality indicators in the current performance frameworks.
The reasons for this imbalance are varied. Coverage data is generally easier to define, collect and analyze than quality indicators which are typically far more complex, the OIG stated. The time horizon is also a factor as, in many cases, quality improvements can be meaningfully and reliably evaluated only over a relatively longer performance period. In the case of the Global Fund, the OIG said, there is also an added complexity as the organization is generally seen as a funding institution whose mandate needs to be carefully managed so as to not overlap with technical agencies that have the remit to set normative guidance and establish quality standards.
“Whilst all these reasons are valid,” the OIG said, “a key fact remains that long term sustainability of the programs supported by the Global Fund is contingent on robust quality of care without which achievements to date can easily be reversed in the future. Given the nature of the issues and some of the challenges highlighted, leveraging partnerships is essential to ensure longer-term value for money from Global Fund investments.”
The ITP initiative has clearly moved the cursor, the OIG said, although it is unclear the extent to which partners are accountable for the delivery of the assigned action items. In addition, the OIG said, the initiative has perhaps overly focused on activities without a clear articulation of the desired impact. “To the Secretariat’s credit,” the OIG said, “the mid-course rebranding of the initiative from ‘Implementation Through Partnership’ to ‘Impact Through Partnership’ implicitly acknowledged this.” The other initiatives mentioned above are evidence that the Secretariat has plans to address many service quality issues, the OIG said. “If implemented successfully, the plans will nevertheless take time to produce results at the portfolio level.”
The Office of the Inspector General 2016 Annual Report, Document GF-B37-12, should be available shortly at www.theglobalfund.org/en/board/meetings/37.