Scale, sustainability and scope in concept notes queried by TRP
The Technical Review Panel (TRP) has released its most comprehensive report yet on the quality and scope of concept notes submitted under the Global Fund's new funding model (NFM), drawing conclusions and identifying trends in the 91 proposals submitted during windows 3 and 4. The report to the Global Fund Board, released ahead of the Strategy, Investment and Impact Committee (SIIC) meeting, flags growing concerns about the scale, sustainability and envisioned success of the activities submitted for consideration for Global Fund support by the country coordination mechanisms (CCM).
Unease that countries were only paying lip-service to the requirements for gender balance and an emphasis on the particular needs of identified key affected populations was apparent. So, too, were fears that countries were neither collecting nor analyzing data appropriately to provide the evidence base for their national strategic plans.
Hoping to tip the balance towards a greater success rate for concept notes -- of the 91 submitted in Windows 3/4, 19 were sent back for revision -- the TRP included a step-by-step guide for CCMs, essentially walking them through exactly what the TRP is looking for in order to approve a concept note.
While the bulk of the 46-page document summarized the trends and deficiencies in concept notes, it also contained a series of recommendations to the Global Fund itself, particularly with respect to the allocation methodology, and again rapped the decision to develop three separate streams of funding -- base allocations, incentive funding and the register of unfunded quality of demand -- as having potentially ruinous consequences for countries.
Below are some of the main points made by the TRP, which build on conclusions drawn in the TRP reports (see articles here and here) that followed a review of concept notes submitted by early applicants and in Windows 1 and 2.
Feasibility, sustainability and scale
Financial sustainability of programming remains a singular concern for the TRP, with the report leading with an observed "growing dependence on the Global Fund to finance and maintain scale-up of HIV treatment, MDR-TB treatment and distribution of long-lasting insecticidal nets for prevention of malaria".
"[U]nless there is a stronger emphasis on financial sustainability, some applicants are approaching the point at which programs will begin to collapse or major components disappear," the report warned, which will not only undermine but potentially reverse gains made in the national battles against the three diseases.
There was also alarm expressed at the low potential in many concept notes for a realistic scaling-up of service deliveries. As an ever-greater number of people begin treatment, the size of the treatment pool is enlarged, leading to a higher burden for maintenance that prevents further expansion. This is most concerning when it comes to those demographic groups that are especially vulnerable to infection, the TRP noted, which may lead to them being "deprioritized in favor of scaling up programs for populations with potentially far less impact on the epidemic".
Long-term planning for sustainable programming was also compromised by unrealistic assessments of system-wide capacity in many countries, the TRP noted. Despite fairly candid appraisals of their own weaknesses in infrastructure and human resources, too many countries were submitting concept notes that implied there would be enough capacity -- both logistical and human -- to meet increased needs of scale and sustainability. Equally, few proposals addressed the "full continuum of care" necessary to manage both the existing disease burden and prevent new infections.
While the TRP noted with appreciation a number of "positive and promising examples" of community system strengthening (CSS) in concept notes submitted in the two windows, the absence of any CSS components in the majority of the proposals -- and others that deprioritized any CSS work by placing it in the above-allocation section of their proposals -- demonstrates an acute need to refocus efforts in this area.
Finally, there was a noted disjunction between interventions and programmatic challenges -- meaning that while CCMs were good at identifying the gaps in services, they were not adequately providing options to fill those gaps. Across all three disease components and health systems strengthening activities, "stronger situational analysis has not always translated into program interventions and budgets".
One example of this disharmony was explained using a concept note submitted by an unnamed country for a malaria grant. While the CCM clearly identified economic migrants as one group exceptionally burdened by malaria infection, there was very little elaboration in the concept note as to how the country intended to meet the specific needs of economic migrants when it came to malaria prevention.
These worries about sustainability extended to those countries preparing to transition away from Global Fund support, either through becoming ineligible under the new burden/income parameters or because of the changing epidemiology of disease.
Many of these transitional countries failed to include a description of an "exit plan" in their concept notes -- particularly when it came to programs targeting key populations that are currently the responsibility of civil society or community-based groups. While the exit plan is and should be the purview of the country itself, the TRP suggested it should be incumbent on the Global Fund to mandate a clear plan for transition from those countries reaching the graduation phase.
Human rights, gender and disease-specific concerns
Nearly universally, the TRP found, concept notes failed to adequately propose "meaningful and effective interventions to address human rights barriers". This includes both targeted activities for key populations who, because of stigma and discrimination or a predatory legislative environment, face numerous barriers in access to health services, as well as activities or community-level work to sustain critical enablers.
"The lack of specific activities for key populations in some concept notes suggested to the TRP that, in some cases, human rights issues were not adequately discussed in the process of concept note development and that key populations were not adequately represented in Country Coordinating Mechanisms," the report said.
Similar concerns were echoed in the TRP's observations about activities specifically designed to meet the needs of women and girls. While some concept notes proposed concrete action to target women and girls, too many others "limit[ed] discussion of gender issues to the background section" or offered "generic solutions to address gender-related issues".
This may be partially attributed to the continued lack of sex-disaggregated data in concept notes -- and within the entire Global Fund ecology as a whole -- as well as to what the TRP identified as a "lack of understanding of effective interventions". How countries -- as well as the partners who are contracted to provide technical assistance in this area -- will evolve their ability to change social norms and endorse more effective interventions going forward remains to be seen.
The Global Fund itself should, according to the TRP, continue to emphasize the need for "social and human rights interventions" while also considering a new requirement for countries that rank poorly on the Gender Inequality Index to address "identified gender issues with concrete activities".
Of the 91 concept notes reviewed during the two windows, 19 were HIV-related including one which, for the first time, demonstrated that "the demands of ART scale-up will exceed available resources within the next year".
The TRP did not elaborate as to which applicant this was but did note that the proposed ART scale-up was prepared "without sufficient consideration of the fiscal constraints faced". This applicant, the TRP warned, was a bellwether for other countries in sub-Saharan Africa where soon ART will not only be unsustainable due to the availability of resources -- both international and domestic -- but will risk crowding out any other programs, including HIV prevention activities, and putting countries in an "ART triage that might produce several negative consequences".
Eighteen TB concept notes were reviewed during the period, the majority of which continued the trend of emphasizing an increase in case notifications in order to fill case detection gaps and address a rising burden of disease.
And while many concept notes addressed MDR-TB and requested funding to expand MDR-TB services, the TRP suggested it would be more appropriate for TB-eligible countries to focus on "the effectiveness and sustainability of their TB programs before scaling up MDR-TB case detection".
For those 20 concept notes from countries required to submit joint TB/HIV concept notes for every proposal that reflected "strong collaboration between the two programs", too many others "still did not reflect the desirable level of coordination, collaboration and integration between the two programs".
There is a persistent perception, among those applicants eligible to submit stand-alone health systems strengthening (HSS) concept notes, that systems are "discrete, almost stand-alone entities". This, according to the TRP, contravenes the need for HSS work to be well-integrated and complementary to the disease focus.
These problems are compounded among those countries identified as "challenging operating environments," where capacity is low and problems immense.
The TRP saw a wide diversity in quality among HSS concept notes, but noted substantial gaps in those submitted from countries identified as challenging operating environments. The TRP is concerned about the capacity of these applicants to develop well-focused concept notes given their challenges and possible capacity gaps. These applicants include countries in conflict or post-conflict settings, with environmental or geographic challenges, or in a fragile state.
Technical support for these countries is critical, the TRP reiterated, and could come from technical partners, other stakeholders or from peers: other countries that have transitioned out of the conflict or post-conflict environment to become a less-fragile state.
Abolish incentive funding, the TRP says. Again.
The TRP used part of the last third of the report to campaign for its most-favored issue: an end to the incentive funding stream and need for applicants to make above-allocation requests. These two components are failing to achieve "the desired outcome of encouraging ambitious, innovative and prioritized interventions" and are, instead, "creat[ing] undue burden on applicants, the Secretariat and the TRP".
Whether from misunderstanding of the complexities of the model, an effort to maximize their allocations, or a host of other reasons, a sizable number of applicants continue to include essential services in their above-allocation requests -- services that could, and should, have been the mainstay of their allocation demand. In having to send these concept notes back, the TRP was contributing to precisely the kinds of delays that the NFM had been designed to avoid.
Nor did the TRP find that applicants were grasping the intricacies of the concept of full expression of demand. "The full expression of demand also creates additional workload for applicants, as it is significant work to articulate the full demand in the modular template and concept note narrative, especially when no funding is guaranteed beyond the allocation," the TRP wrote.
Beyond the administrative impact of the additional streams, the TRP said, was the potential impact on the Fund's relationship with countries, placing a burden of "unrealistic expectations" on the Fund from countries disappointed by their allocation levels which could then lead to "decrease[d] mobilization of domestic financing". Another damaging consequence, according to the TRP, is that they may "undermine a country’s interest in meaningfully prioritizing interventions".
To mitigate these potential hazards, the TRP urged a swift but deliberate re-examination of these concepts in order to revise and streamline the processes of the funding model in good time, ahead of the replenishment set for 2017.
"The TRP strongly advises the Secretariat and the Board to clarify the Global Fund’s objectives for the allocation and to re-evaluate the methodology before the next replenishment," the report said. "If the objective of the Global Fund is to reduce mortality and morbidity rather than eradicate diseases, the methodology should more accurately reflect the most strategic investment of resources."