Uniting Forces for Global Health: The Transformative Partnership of the Global Fund, Gavi and the Global Financing Facility (GFF)

Author:

Ida Hakizinka and Christian Djoko

Article Type:

Article Number: 4

In October 2023, Gavi and the Global Fund launched four workstreams to strengthen their collaboration, with the recent inclusion of the Global Financing Facility (GFF). Progress was reviewed at the Strategy Committee meeting in March, together with the proposal for a joint working group between Gavi, the GFF and the Global Fund, in the wider context of the Lusaka Agenda. The Strategy Committee supported the continuity of the four workstreams and recommended the creation of a joint working group to facilitate their implementation, subject to clarification and review by the Ethics and Governance Committee. These discussions were presented to the 51st meeting of the Global Fund Board to seek its advice on how to further improve collaboration and communication between the three global health initiatives, as well as the need to identify key missing elements in each of the four workstreams and to support the formation of a joint working group. What is the future for collaboration between the Global Fund, Gavi and the Global Financial Facility? This article reports on these discussions.

Introduction

The Secretariat of the Global Fund prepared a paper for discussion at the 51st meeting of the Global Fund Board. The paper, on the current and future collaboration between three major Global Health Initiatives, namely, Global Fund, Gavi, Global Financing Facility, included three questions that required the Board’s response:

 

1. What are some ways that we can improve our collaboration and communication across all three GHIs?
2. Does the Board think there are any key missing elements in each of the four workstreams?
3. Does the Board of Directors approve of establishing a Joint Working Group for the three different workstreams?

 

The landscape of global health is dotted with many organizations, each playing a pivotal role in addressing health crises around the world. Among these, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Gavi, the Vaccine Alliance and, the Global Financing Facility (GFF), make critical contributions to global health security in their efforts to combat and prevent some of the most challenging diseases in the most affected and low- and middle-income countries. The three organizations mobilizing and investing billions of dollars in health systems, disease prevention, and treatment have saved millions of lives. Here’s how they do it (Figure 1).

 

Figure 1: Gavi, Global Financing Facility & Global Fund

This partnership is especially crucial in today’s context, where health challenges are becoming more complex and interconnected, requiring unified efforts from all stakeholders in the health sector. These challenges include the emergence of new pathogens, the increasing burden of non-communicable diseases, and the persistent threats posed by AIDS, tuberculosis, and malaria. Moreover, the fiscal environment for health is increasingly constrained, necessitating more efficient use of resources to sustain the gains made in health outcomes and to push further towards elimination goals.

The coordination, alignment and collaboration between donor organization has been a persistent demand since many years starting with the Paris Declaration 2005 (Figure 2) and the latest initiative being the Lusaka Agenda, which calls for alignment of common goals as well as complementarity in their approaches.

 

Figure 2: Principles of Paris Declaration, 2005 for Aid Effectiveness

Source: https://www.oecd.org/dac/effectiveness/45827300.pdf

 

Operationalizing the Enhanced Partnership

The formation of a proposed Joint Working Group in October 2023,  focusing on malaria, health systems strengthening (HSS), and country engagement, marked a pivotal step in this enhanced collaboration, initially between the Global Fund and Gavi, expanded to include back office cohesion and involved the GFF as well in two of the workstreams (HSS and country engagement) mentioned below. To operationalize this enhanced collaboration, the three organizations have developed specific workstreams (Figure 3), co-led by staff members from Gavi, GFF  and the Global Fund.

 

Figure 3: The Four Workstreams in the Gavi, Global Financing Facility and Global Fund Partnership

 

By streamlining efforts across these critical areas, the partnership is poised to deliver more comprehensive and effective support to countries. This collaborative model emphasizes prioritizing areas with significant overlap, ensuring that every effort is directed towards maximizing country impact (Figure 4).

 

Figure 4: Overview of collaboration between the Global Fund, GAVI, and the GFF – Towards Country Impact

 

 

Malaria

 

Malaria remains one of the world’s deadliest diseases, particularly in sub-Saharan Africa (see our recent articles on the subject here 1, 2, 3, 4). The Global Fund and Gavi have committed to leveraging the full malaria toolkit through their collaboration, focusing on complementary programming, communications, funding, and replenishment approaches. The joint malaria workstream has developed a model that leverages the strengths of each organization and, optimizes the delivery and impact of the full range of malaria interventions, from vaccines to bed nets and antimalarial medications. This includes aligning funding cycles and communications strategies to maximize awareness and uptake of malaria prevention and treatment options. The upcoming rollout of the R21 malaria vaccine exemplifies the urgent need for alignment. And underscores the potential of this collaborative approach to bring innovative solutions to the forefront of malaria prevention and treatment. As a promising new tool in the fight against malaria, its introduction and scale-up provide a timely opportunity for Gavi and the Global Fund to harmonize their efforts, ensuring that countries are supported comprehensively in their vaccination and disease control strategies.

 

Health System Strengthening

 

The Health System Strengthening initiatives, which has called for a concerted effort and includes GFF, focuses on developing a united strategy to improving health systems. This includes collaboration on Metrics and data and Health Management Information Systems (HMIS), supply chain management, and Community Health Workers (CHWs). Case studies from several nations demonstrate the real benefits of this coordinated strategy, highlighting advances in supply chain efficiency, data management, and community health services. As part of strategic alignment, it involves mutual participation in strategy-setting forums and technical advisory groups (Gavi 6.0 Health Systems strategy technical advisory group, GFF supply chain strategy, Global Fund contributory RSSH methodology review technical advisory committee, Global Fund RSSH metrics consultation The widening of the Global Fund’s pool for technical expertise in RSSH through GAVI was also recommended to it by its Strategic Review 2023.

 

Strong health systems are essential for the effective delivery of health services, such as immunizations and disease prevention programmes. The collaboration in HSS (Figure 5) seeks to improve in-country coordination of investments in health systems, service delivery, and monitoring and evaluation (M&E) frameworks. Align investments and efforts to strengthen health systems, with an emphasis on healthcare personnel training, infrastructure development, and supply chain optimization. This includes working with implementing partners to collaborate on HSS metrics, enabling a consistent approach to assessing progress and impact.

 

Figure 5: Key opportunities for deepening collaboration in HSS between the Global Fund, GAVI, and the GFF – A Summary

 

Country Engagement

 

The enhanced collaborative engagement of countries is an initiative that aims to simplify country-oriented processes through Gavi, the Global Fund, and the GFF. This involves increased collaboration between these organizations to achieve common goals. The GFF mobilizes funding in several ways. One of them is complementary financing, where partners with programs in countries, like Gavi and the Global Fund, are encouraged to align their financial resources to achieve common goals, thus increasing efficiency and avoiding duplication of efforts. In addition, the GFF works with the finance and health ministries of the respective countries to allocate existing and additional resources where they are most needed.

 

Back Office Coordination

 

The collaboration extends into optimizing back-office functions and operations, with initiatives aimed at enhancing operational efficiency across the partner organizations. Collaboration extends beyond programmatic areas into back-office functions, where efficiencies and synergies can be found to support the organizations’ broader goals; and identifying opportunities for collaboration across business-enabling functions, such as IT, HR, administration, and operations. The aim is to improve effectiveness and efficiency, reducing overheads and freeing up more resources for frontline health interventions.

 

It extends to different areas in which translation services, travel and travel safety, IT purchases and contracts, as well as treasury are examined for shared use between Gavi, UNITAID, and the Global Fund. It also mentions the use of the Global Fund’s AI-based translation tool and the common approach to environmental sustainability. This systematic approach to collaboration seeks to improve effectiveness and reduce overhead, allowing for more resources to be allocated directly to programmatic work.

 

Public Financial Management

 

A significant focus of the partnership is strengthening public financial management and enhancing accountability. Joint interventions aim to bolster the financial management capacities of health programs and ensure transparent and effective use of resources. This collaborative effort underscores the partners’ commitment to sustainability and accountability in global health financing and the usage of in-country systems . The  usage and strengthening of the in-country accountability mechanism to address both financial and programmatic risks have been highlighted including the Supreme Audit Institutions as key stakeholders.

 

In addition to the key areas of collaboration previously outlined, aligning Gavi and the Global Fund’s co-financing, transition and sustainability policies, represents a crucial strategic alignment. Such alignment can ensure a more seamless and impactful transition for countries moving towards greater health financing self-sufficiency given the limited fiscal spaces and counterpart financing requirement the countries are receiving from multiples donors. This is particularly relevant as countries transition from donor support, facing the challenge of sustaining gains in health outcomes.

 

The three organizations can work together to harmonize their co-financing requirements and transition policies. It is to be noted that the Strategic Review pointed out that Gavi’s co-financing requirements are sterner in enforcing it while the Global Fund leaves the process of waivers and exemptions to negotiations between their country teams and country stakeholders. Hence, it will involve aligning timelines, requirements, and support mechanisms for countries expected to increase their financial contributions to health programs. This will help to create a more predictable and supportive environment for countries facing transition, minimizing risks of service disruption, or backsliding on health gains. By coordinating their policies, Gavi. GFF and the Global Fund can help ensure that countries are better prepared for transition, with robust systems in place for domestic financing for health.

 

Selection of Focus Countries

 

The collaborative model between the Global Fund, GFF and Gavi is a dynamic framework designed to adapt to the specific needs and contexts of focus countries. This model prioritizes strategic alignment and optimization of efforts across various workstreams to ensure the maximum impact of health interventions with an emphasis on the alignment across key areas of intervention, shared objectives, and streamlined operations to enhance the efficiency and effectiveness of health programs. The selection of focus countries is a critical process, guided by criteria that consider disease burden, the potential for impact, and the readiness for transition to sustainable health financing.

 

In order to identify and collaborate with pathfinder countries effectively, a structured bottom-up approach will be implemented in four key steps:

 

The selection process involves both quantitative analysis and qualitative assessment, with input from country-level stakeholders, technical partners, and internal experts from both organizations. It involves a comprehensive analysis of several factors:

This collaborative approach ensures that selected countries are those where joint efforts can truly make a difference, considering both immediate health needs and long-term sustainability goals.

 

Examples of Impact in Focus Countries

 

In countries where the Global Fund and Gavi have focused their collaborative efforts, tangible improvements in health outcomes and system performance are evident. For instance, in regions with high malaria burden, joint efforts have led to the expanded coverage of malaria prevention measures, including the distribution of insecticide-treated nets and the introduction of the R21 malaria vaccine, resulting in significant reductions in malaria incidence and mortality.

 

In the realm of health system strengthening, collaborative projects have supported improvements in supply chain management, ensuring the availability of essential medicines and vaccines. This has been particularly impactful in challenging operating environments, where coordinated efforts have overcome logistical and infrastructural barriers to health service delivery.

 

The Global Fund, Gavi and GFF have collaborated with other partners for training civil society organisations in Africa on the Joint Learning Agenda for advancing health financing and Universal Health Coverage. The Global Fund has also collaborated with the World Bank and GFF on tracking its resource mobilization and expenditure to improve tracking of health resources, both domestic and external (including through catalytic investments). In April 2024, the Global Fund, GFF and the World Bank also co-hosted a session on “One Plan One Budget One Report Agenda”, at the 7th Annual Health Financing Forum, held on the sidelines of the World Bank/IMF Spring Meetings.

 

These examples underscore the potential of the Global Fund, Gavi and GFF partnership to transform health landscapes in focus countries. By aligning their strategies, resources, and expertise, they are not only addressing immediate health challenges but also laying the groundwork for sustainable health improvements.

 

Stakeholder Feedback

 

Stakeholders emphasize strategic alignments and collaborative momentum in the global health community, particularly among Gavi, GFF, and the Global Fund. They strongly support the initiative to establish a time-limited Joint Working Group (JWG) to focus on critical workstreams such as malaria, health system strengthening, and country engagement. Stakeholders emphasize the group’s importance in fostering a unified approach and ongoing dialogue among the participating organizations. They believe that clear, regular communication with governance bodies, as well as a commitment to detailed, shared objectives, are critical for improving the effectiveness of their collaborative efforts and addressing specific health-care system challenges. Furthermore, the emphasis on strong coordination in the health system strengthening workstream is viewed as critical to optimizing resource utilization and improving service delivery across countries.

 

This cooperative stance is supported by feedback from a wide range of global partners, who emphasize the importance of improved communication and strategic alignment facilitated by the Joint Working Group. There is widespread agreement on the need for a well-defined framework that not only ensures accountability but also maintains an agile operational structure capable of adapting to the changing needs of global health challenges. Stakeholders agree on the importance of including a diverse range of voices, including NGOs and community representatives, in the JWG to ensure that the initiatives are comprehensive and inclusive. There is a clear path to a more integrated and impactful global health architecture if strategic alignments that leverage each organization’s strengths are prioritized. This collaborative model seeks to not only streamline efforts, but also to increase the impact of health interventions by improving synergy and resource sharing among key global health initiatives.

 

It should be noted, however, that the stakeholders warned against the assumption that increased efficiency should lead to reduced funding needs. They underscored the ongoing substantial needs in healthcare systems and advocated for sustained, if not increased, resource allocation. At the Board meeting in Geneva, stakeholders collectively stressed the importance of involving community service organisations (CSOs) to foster inclusive and effective collaborations. There were also calls for increased visibility of Board activities and enhanced collaborations as also for regular formal sessions to maintain communication and oversee progress in initiatives.

 

They also encourage the engagement of the World Health Organization in the JWG, given its role as the directing and coordinating authority in international health. There were also calls to get down to the nitty-gritty and identify the pathfinder countries with implementer countries asking to be among them and for not locating the JWG office and secretariat in the donor countries so as to track UHC better. Some stakeholders believe that the JWG should focus on improving the coverage of essential services, enhancing the quality of services, and reducing out-of-pocket expenditure to achieve UHC objectives. Certain stakeholders expect the JWG to provide biannual reports to the Global Fund Boards. They also requested the Secretariat to share potential risks and limitations of forming the JWG. The aim is to shape the current Global Health Architecture through the JWG, ensuring it drives real change rather than merely serving as a formality.

 

Conclusion

 

A robust governance structure and strong accountability mechanisms are essential to ensure that this partnership is more than just aspirational dialogue among boards. This should include a concrete action plan with clearly defined milestones, regular progress updates to stakeholders, and transparent, rigorous mechanisms to hold all parties accountable for their commitments. Through sustained commitment and strategic action, this alliance has the potential to turn aspirations into tangible health improvements, ensuring the long-term success, sustainability, and resilience of health systems globally.