Global Fund: Do your homework on Resilient and Sustainable Systems for Health!
Author:
Aidspan
Article Type:Article Number: 6
A critique of the Global Fund’s approach to health systems strengthening, it delves into various reports generated by the Global Fund on Resilient and Sustainable Systems for Health (RSSH) to examine what it is not saying and what it needs to do rather than be prescriptive. The article is in the context of the Global Fund Strategy Committee meeting on July 10, 2024, which reviewed the working of the RSSH component.
At the Strategy Committee meeting, scheduled for July 10, 2024 members were asked to answer a number of questions concerning the strengthening of the healthcare system. To this end, documents were shared which have been produced over the last 6 years: Technical Review Panel (TRP) recommendations and analyses, mapping of investments on the Technical Evaluation Review Group’s (TERG) request, proposal of a new framework for reflection and evaluation of the Resilient Sustainable Strengthening (4S). This is the maturity model of the health system where the 4S refers to the stages of start-up, support, strengthening and sustainability, and forms the analytical framework for investments in Resilient and Sustainable Systems for Health (RSSH).
The pitfalls of overly theoretical thinking disconnected from existing tools
On reading the documents, we are surprised to see the extent to which the analysis is focused on the system and on the Global Fund’s priorities, and not on patients, despite an evolution of the conceptual framework promoted by the World Health Organization (WHO), and which is not recent. It seemed that we had moved beyond the false cleavages linked to the questioning of the contribution to the system of the delivery of HIV, TB or malaria services versus own Health Systems Strengthening (HSS) actions. However, these reappear in the document, despite the fact that we have long since moved on, and that the reflection we are now concerned with is linked to the functionality of service delivery platforms that are as comprehensive as possible. For, if seeking care is a costly experience, difficult in certain environments, and sometimes at odds with socio-cultural norms, then it must be made as accessible as possible. The WHO’s definition of quality is broad enough to suit everyone, and makes it easier to assess the functionality of health facilities for patients. Is the patient experience improving? Does it enable them to diagnose their pathologies correctly, to treat them without ruining them, and to identify any other health problems that can be addressed?
There is little mention of the other health sectors, which carry more weight than HIV and TB, and which must be grafted onto existing platforms: diabetes, hypertension, maternal and neonatal health, cardiovascular diseases. The documents speak of integration (notably between the 3 diseases and HSS), but fail to mention integration with the rest of the priorities, which are nonetheless urgent because they weigh on the financing of the current system, and include a significant prevention component. Good prevention of diabetes and hypertension, as well as efforts to engage women in Ante Natal Care (ANC) and Post Natal Care (PNC), will have an almost immediate impact on health indicators. Isn’t that what we’re aiming for?
The Global Fund’s responsibility for improving coherent and aligned planning and implementation
The TRP RSSH Deep Dive conducted by the TRP and the Office of the Inspector General (OIG) Contributory Review suggest that the Secretariat should be more prescriptive about the priorities that the Global Fund will agree to finance in the next GC8 cycle, and develop its theory of change for what is expected from these HSS investments. Such suggestions raise questions about how we see the role of the Global Fund in relation to recipient countries. And what remains of the principle of country ownership. For if priorities are to be identified, they must come from the Ministries of Health (MoH), which must, on the basis of their national strategy (the National Health Development Plan), decide what they want to propose to the Global Fund. The Global Fund has a number of specific features that need to be taken into account: funding is secured for a 3-year period, the implementing actors can be ministries of health (no obligation to go through a specific unit or UN agency), and HSS investments already committed in previous cycles often require continuity. Rather than being prescriptive towards countries, it is advisable to be more committed to alignment between donors, and to simplifying cumbersome procedures, reporting and multiple auditing requirements that may impede effective implementation.
In recent years, there has been a significant increase in investment in health systems strengthening (HSS). However, these funds are not always well-coordinated. The investments in HSS are spread across different funding processes such as the Disease-Specific Grant Cycles, standalone grants for HSS, and the Covid-19 Response Mechanism (C19RM). Due to the short time frame for funding requests, disease-specific funding requests occur simultaneously in various locations, leading to fragmented discussions and a lack of alignment, with a focus only on disease-specific aspects of HSS. Furthermore, implementation arrangements often involve multiple grants as part of disease-specific programs, while the implementers of HSS are often from MoH Directorates different from those responsible for disease programs. At the end the Global Fund HSS investments do not have the same timeframe or performance frameworks, and these also include the countless catalytic funds as well for funding in priority areas of RSSH that may not be adequately covered under the country allocations.
Added to the Global Fund (GF) grants is funding from those of its partners such as the Warren Buffet Foundation, and then the countries’ multilateral and bilateral partners such as Gavi, the Alliance for Vaccination, the World Bank, USAID, not to mention other private sectors et al. All these donors independently of the GF finance the strengthening of the health system according to their own modalities, with priorities that they may set unilaterally from their own strategic plan investments, differing implementation modalities and procedures, and specific timetables and reporting and auditing models. This creates competition between donors, as costs are not harmonized, implementing actors favor funds which are more flexible and are easy to commit and justify rather those from Global Fund grants. Hence, complementarity is not ensured, on the contrary, it’s common to encounter situations where proposals overlap with multiple duplication.
If GC8 calls for an even greater streamlining effort, it’s time to change these harmful working habits, before proposing new theories of change. Do your homework: align yourselves among donors, support the central services of ministries facing their own planning and implementation difficulties, and measure your success against existing indicators (service utilization rates, rates of preventive and curative services, incidence of major pathologies).
As the Office of the Inspector General (OIG) pointed out in its report on the evaluation of the strategy, the partnership that seems to be working well for the 3 diseases has not yet taken shape for HSS. And while efforts have been made between headquarters, in-country communication is poor: each donor runs its own projects without concern for the others, transparency and information sharing remains difficult, and planning rhythms prevent the Ministry from calling for alignment around its priorities. Unfortunately, the Global Fund Country Coordinating Mechanism (CCM) contributes very little to this search for alignment between donors as its mandate is only for the GF resources, even though many other HSS donors do have a seat in the CCMs, and this should be one of its priority tasks along with advocacy for higher co-financing and domestic resources for health and not only for disease-specific activity. There needs to be a more aligned donors’ co-financing requirements as most of them are addressed to the same Ministries of Health and Finance.
There is a need to simplify procedures and to look for solutions to the main bottlenecks: procurement, lack of flexibility in reprogramming with sometimes too many delays in the feedback from secretariats (A Reprogramming request can take more than 6 months to be approved with multiple back and forth), and in Challenging Operating Environments (COE) that have to live with a fiduciary agent, ensure that the latter understands the commitment that binds them to financial and programmatic performance.
Against a backdrop of dwindling resources for the GC8, and in which recipient countries are themselves struggling to finance their health systems, it is intolerable to see funds flowing back to Geneva, particularly those for HSS. For these are the only funds that benefit the entire system, and also enable strengthening the quality and availability of care for pregnant women, children and patients suffering from pathologies that have become the epidemiological crises of the 21st century.
The Global Fund has chosen to strengthen these systems in the long term, and this implies a change of model that we’re going to have to accept, rather than making technical adjustments that are merely band-aids on a wooden leg. Securing funding to strengthen the system, making its management uniform to relieve ministries that need to be able to rely on several sources of funding, placing ourselves at the level of the implementers to make their task easier, and remaining flexible in possible re-orientations or scaling up are the basis for these funds to be effective.
After 22 years of existence, it’s time for the Global Fund to assume its responsibilities by supporting the country in its HSS action planning, and facilitating the MoH for inter-donor financing and coordination so as to plan complementarity of disparate funding organizations/agencies for fulfillment of the country’s strategic priorities. The Global Fund’s investments in strengthening the system will only be effective if they reinforce good governance of health financing and support the country’s epidemiological priorities in a consistent way with other donors. There is no need for new models, specific guidelines and indicators as countries follow WHO recommendations and have their own systems. Take leadership in supporting long-term countries’ priorities, provide adapted tools required by the MoH to better plan and follow up the activities that contribute to meet the population health needs and play a role model of transparent and efficient partnership with ministries.
