During the new 2020-2022 funding cycle, and for the first time since the beginning of the new funding cycle in 2014, the Global Fund guidelines called for systematic investment in health system strengthening. This was based on the recommendations in the Technical Review Panel’s (TRP) report on resilient and sustainable systems for health (RSSH) investments.

The allocation letters sent to recipient countries emphasize the importance of system strengthening activities. All letters to Country Coordinating Mechanisms (CCMs) indicate that “the Global Fund encourages applicants to invest in health and community system strengthening as they are essential to halt epidemics.” The Global Fund Secretariat welcomes:

• initiatives to develop and strengthen patient-centered integrated care. These include initiatives that address co-infections or provide coherent packages of care, such as integrated antenatal services.
• investment in support services, which are needed to impact and sustain disease control programs. They include laboratories, supply chains, data systems, community monitoring and mobilization, advocacy and organizational development, and human resources in communities and health facilities.

Conflicting injunctions and missed opportunities

Despite the emphasis on health system strengthening, the Global Fund Secretariat has not set aside a predefined package for activities that promote RSSH and has actively discouraged the development of stand-alone RSSH grants. Each CCM was expected to lead discussions about the allocation of funding for the four components: tuberculosis (TB), HIV, malaria, and RSSH, and ultimately chose the option of placing RSSH activities within the disease grants.

There has been a lack of guidance and tools to develop a common understanding of how health system strengthening activities contribute to combatting the three diseases. This has led to unhealthy competition between the three disease programs and other departments who have attempted to limit disease resources to fund RSSH. Disease programs were dissatisfied with those cuts as programmatic gaps remain. “Parts” of grants have been removed from the disease components in order to compose an RSSH package often fragmented between the various grants, without coherence and vision. In a report seen by Aidspan, the TRP found this to be detrimental. Aidspan also drew attention to this in an article on RSSH training arranged by the Global Fund Secretariat and GIZ in 2019.

According to the information received, most of the Global Fund country teams have strongly advised CCMs to include RSSH components in disease packages. The reasons for this could be that they wish to avoid appointing a PR for RSSH activities, and avoid problems with reporting on RSSH implementation, which is generally slow and poorly coordinated.

This painful process of reducing the funds for diseases has discouraged further discussions on RSSH: in most countries, disease programs (HIV, TB and malaria) have lost interest in system-strengthening activities, which they see as ‘add-ons’ (for which they anticipate implementation difficulties), or worse, expenditure that deprives their disease programs of funding.

Given the short time allotted to draft applications and COVID-19 movement restrictions, disease consultants often did not collaborate with those in charge of RSSH. This meant that RSSH consultants had to formulate activities to support the fight against the three diseases. Furthermore, health officials, whose input was required, were caught up in the response to COVID-19.

Lastly, health programs drafted their applications, without having discussions with the departments responsible for RSSH: health information, pharmacy and drugs, laboratories, primary health care (which usually includes community health), and planning.

The TRP noted that current and previously assessed funding requests failed to demonstrate the expected impact of RSSH activities on the diseases. RSSH modules were presented in the disease grants without any clear link to or discussion of their impact on the three diseases. Few of the applications managed to present a clear strategy for system strengthening.

The TRP highlighted the difficulty experts faced in analyzing RSSH components, as they were spread across various grant applications that were submitted in different windows. The TRP Chair, Dr Patricia Moser, noted this at the Global Fund Board meeting held in May 2020.

What has been learned from this grant renewal cycle?

The past six months have been instructive as they have tested the concepts and tools that the Global Fund has developed to guide the thinking and drafting of RSSH components.

Country teams learned that health system strengthening is multifaceted and complex and needed to be integrated into systems. They needed solid training to participate in and support the discussions. In its report in 2019, the Office of the Inspector General (OIG) emphasized that the Secretariat needed to improve the management and framework of RSSH to make it operational. The OIG had warned that the Secretariat lacked RSSH expertise.

The few experts in the RSSH department, the main provider of expertise within the Secretariat (together with experts on the supply chain, laboratory and data) have acknowledged that they rely on country teams to request documentation, Global Fund tools, assistance and advice on how to prioritize activities and set out technical aspects in the modules of the funding application. Overwhelmed by the workload (one RSSH expert covers about 10 countries) and overly ambitious timelines (an average of 40 applications submitted in some windows) it has become impossible for them to carry out refined analyses. RSSH experts lose sight of the RSSH activities as negotiations for funding proceed.

Initial feedback from the grant-making phase suggests that RSSH experts are no longer consulted during this crucial phase that determines the activities selected and their respective budgets.

The CCMs regretted that their members were unprepared in terms of their RSSH applications:

• They lacked mature relationships with departments within the ministries of health; there was no regular collaborative interaction with some departments within the Ministry of Health.
• Country teams were not prepared for discussions on RSSH activities and their governance.
• Assessments on the implementation of RSSH activities in the current cycle were not conducted.
• Priorities were not identified or discussed upstream.
• Performance Indicators for RSSH were often non-existent or too old.
• Description of RSSH activities were not available at the Global Fund or from CCMs.
• CCMs had not been able to promote the idea that a national recipient, attached to the Ministry of Health, should be responsible for RSSH.

Lastly, the consultants noted that often the planning for RSSH was not discussed with other health donors, in particular Gavi, the World Bank and the European Union. Their efforts to map ongoing investments and take them into account (to avoid duplication and maximize the Global Fund’s investment in the country) were hampered because time was limited and it was difficult to obtain documents from donors.

What options are available to the Global Fund to make progress on RSSH?

The Global Fund has begun consultations to develop its new strategy. This process, which will last one year, is an opportunity to once again reflect on and discuss the subject, and to particularly:

• Revisit the definition of health system strengthening. While it is clear that a definition exists as a result of the World Health Organization’s (WHO) efforts, its application seems artificial. While the Global Fund designs RSSH as a project, within the ministries of health, it is the National Health Strategic Plan which, in its 10-year vision, sets the objectives for improving the system. There is no centralized management of RSSH. Therefore, there is no single focal point. The Global Fund needs to review its own objectives.
• Make a strategic choice in terms of RSSH:
  • Carry out adjustments (necessarily at the margin), make the tools for planning RSSH activities operational, and create tools to monitor their implementation. In this case, the RSSH “strategic pillar” of the Global Fund will be renewed.
  • Re-examine the whole issue of RSSH and treat it as a unique element, with its own structure because it allows for long-term planning, beyond the three-year cycle and could be unrelated to the funding cycle. It allows the Global Fund to position itself as a key player in a strategic dialogue with the different departments within the Ministry of Health. Additionally, the Global Fund can form real partnerships with health donors who finance RSSH and facilitate RSSH pilots in the ministries of health in recipient countries. Planning, implementation and evaluation (technical and financial audits) could be conducted jointly within a specific period with uniform tools.

• Lastly, it is necessary to once again place the patient at the center of RSSH. The patient is the primary objective of all system strengthening activities. To increase the impact of these activities on diseases, patients’ experiences must be analyzed in order to understand their needs, the obstacles they encounter in seeking care, and to take the services closer to them. It is also necessary to analyze the demand for healthcare and the factors that influence it: perceptions and understanding of diseases, traditional methods of disease treatment, gender inequalities, beliefs, culture, and religion. Only then will RSSH strategies make sense.

Further reading

• TRP, Report on RSSH investments in the 2017-2019 funding cycle (in English only), Oct 2019
• Audit report, Investment management for resilient and sustainable health systems, Mai 2019 (GF-OIG-19-011)