Eighteen months ago, we reported on the launch of the Global Fund’s Strategic Initiative (SI) Differentiated HIV Service Delivery (DSD), one of 19 SIs, that had been launched slightly later than expected due to the impact of the COVID-19 pandemic. The SI workstream totals $343 million in the 2020-2022 allocation period and is one of three modalities for funding catalytic investments (CIs) — the others being multi-country approaches and matching funds. They support the success of country allocations but cannot be funded at the country level due to their cross-cutting or off-cycle nature. However, they are vital to ensure country allocations deliver according to the Global Fund Strategy and were a hot topic for discussion at the recent Board meeting when plans for the 2023-2025 CIs were unveiled. As the new cycle of CIs is being discussed and decided on, we bring you an update on the preliminary results of the DSD SI from four of the ten focus countries. Ten countries are benefitting from the DSD Strategic Initiative The DSD investment focuses on achieving public health impact through scaling-up DSD models or service delivery adaptations for testing and treatment in ten countries and providing learning and tools for portfolio-wide implementation in the next funding cycle. Four of the ten countries (Mozambique, Nigeria, Tanzania and Zambia) are guaranteed funding for the entire implementation period from 2021 to 2023. The other six countries (Cameroon, Côte d’Ivoire, Ghana, Guinea, Indonesia and the Philippines) are receiving a continuation of funding for the entire three-year cycle if they can demonstrate progress against implementation milestones by the middle of the implementation period. A related $25 million matching fund investment was also provided to Cameroon, Mozambique, Nigeria, Tanzania and Uganda for the 2021-2023 implementation period beyond their core allocations to support the scale up of HIV-self testing (HIVST) in the context of differentiated HIV testing services. These funds were made available to incentivize the programming of the country allocation towards HIV testing. The SI provides expert international and national technical assistance (TA), overall coordination (World Health Organization/WHO) and evaluation and learning (Clear Outcomes/Bixal). Evaluation methodology The original summative (beginning, mid-term and end) evaluation methodology was replaced with a more developmental, continuous, and agile approach with distinct evaluation and learning cycles. Its purpose was to document the start-up and early implementation of the DSD SI in selected countries, assess any preliminary effects on grant implementation, and share best practices and lessons learned. This first learning activity was built around four key questions (Figure 1). Its scope was defined by the selection of four focus countries with a faster/more successful DSD SI start-up (Cameroon, Ghana, Guinea, and Mozambique) and one country with a delayed start-up (Indonesia). Figure 1. Evaluation questions To answer the questions, the evaluation team conducted a document review and 17 key informant interviews with Global Fund country teams (GFCTs), Principal Recipients (PRs), Ministry of Health (MOH) staff and in-country WHO representatives. Current implementation status The first question looked at where the countries were in terms of DSD SI implementation and what has facilitated or hindered start-up. A few countries kick-started implementation during the grant’s first year. Ghana began implementation in July 2021, with its formal DSD launch in September 2021. Cameroon, Guinea, Nigeria, Mozambique and Zambia began implementation in late 2021. The remaining countries have begun or will begin this year. Figure 2. DSD SI timeline showing start-up It should be noted that the first deliverable date is the date registered on the Purchase Order as the start date. The first deliverable is a product of at least one or more months of implementation. Perhaps partly due to its success as an adapted service delivery mechanism to address the impact of the pandemic, DSD is a ‘hot topic’. In fact, the DSD SI has seen increased demand from countries across West and Central Africa, the Middle East and North Africa, and Southeast Asia. As a result, the Global Fund’s Grants Approvals Committee (GAC) approved an additional $2.6 million to address DSD SI demand from eight additional countries. There are many partners supporting DSD implementation. The DSD SI involves several participating organizations which has resulted in a long selection, planning and procurement process and the need for additional coordination both with the DSD SI partnership as well as with other DSD implementers and stakeholders.

“…what facilitated the start-up process in Ghana was the greater involvement of key partners (especially the GFCT, WHO Ghana office, MOH in Ghana, civil society organizations, other donors) from the beginning of the DSD SI process. The technical person from the GFCT was consistently updating the in-country partners on what the DSD SI was, what activities could be done under the SI and what activities couldn’t. For any challenges we faced, we could go back to them and ask for guidance and/or clarification.” Ghana, country stakeholder respondent

Factors affecting start-up The DSD start-up was influenced by WHO’s regular coordination of the different DSD SI partners and broader DSD stakeholders and, in some countries, the MOH. There was trust and confidence in the selected TA providers (who were known, respected, and had in-country experience). Additionally, if the main HIV grant already had an existing focus on DSD, this was a facilitating factor. The sharing of early TA outputs, as in Ghana, created confidence in the process. How quickly the activities were launched was affected by the number of stakeholders involved in DSD in general, and for the DSD SI specifically. While it was undoubtedly a good thing that DSD engaged so many stakeholders and in some cases facilitated the process (see the text box above), this also led to an increased need for coordination, confusion, overlap or gaps in the scopes of work. The lack of involvement of PRs and GFCTs in the design of the DSD SI and in the country selection process also affected start-up. Why were some focus countries quickly able to start their DSD activities? While the planning phase took longer than initially anticipated, the factors that contributed to a rapid start-up were similar to those described above. Regular meetings provided structure to the planning and implementation processes. In some countries, WHO played an important facilitation role (for example, WHO headquarters and the Mozambique MOH; the WHO local office in Ghana). Dedicated stakeholders often make a significant difference; identifying and supporting DSD champions can facilitate start-up. MOH and PR involvement in the selection of TA providers ensured that appropriate providers were selected (e.g., with in-country presence, respected, and having prior country and DSD knowledge/experience). The selected focus countries used the DSD SI potential to catalyze DSD implementation within the regular country allocations/HIV grant The review of the four focus countries showed a potential for the DSD SI to be catalytic in supporting DSD SI scale-up and implementation. However, it is too early in the program cycle to demonstrate evidence of this impact. Early evidence In Cameroon, the DSD SI is based on a national testing DSD analysis and plan which facilitated the process and is part of the CQUIN project which already has a pre-existing DSD plan and monitoring process. This has facilitated an earlier start-up than would otherwise be expected. Ghana’s effective combination of local coordination (WHO), a local TA organization (EQUIP Ghana) with Global Fund experience, some international support (Jphiego TA and CQUIN, a growing network of countries working together to advance the scale-up of high quality differentiated HIV services), virtual activities (Sexual Health 24 hours a day/SH:24), and a pre-existing country focus on DSD (in Ghana’s main HIV grant) has the potential to demonstrate catalytic effects, especially given the fact that the local TA can provide support for DSD implementation at the facility level. Guinea’s DSD SI provided TA provider SOLTHIS, who was already running a regional project on HIVST, now has more space and funding to implement an HIVTST self-testing strategy to improve their first ‘95’. Integration of DSD SI efforts should improve grant performance Mozambique’s DSD SI led to increased collaboration and coordination among DSD stakeholders — showing an early catalytic effect. The demand creation materials may also prove to be similarly helpful in the coming years. Catalytic potential At a broader level, there are questions around the catalytic potential of the DSD SI that need to be taken into consideration and addressed:

• Is the investment/budget sufficient to have a catalytic effect?
• How can we ensure that all the different DSD SI initiatives are coordinated to provide maximum impact?
• Given the challenges of multiple SIs, how can we ensure good collaboration and complementarity between the different GF funding mechanisms in order to create/enhance the multiplicative effects of each SI?

These are important questions when considering the next iteration of SIs/Cis for the forthcoming allocation period. Current feedback/best practices from DSD SI start-up and early implementation While feedback and best practices emerging from the four countries were varied and context-specific, they can provide guidance to the other DSD SI countries (depending on their context). Rather than general lessons learned, the findings and feedback from the four focus countries were used to develop a set of best practices. These are not ‘one size fits all’ but interested stakeholders can select the most appropriate ones for their context. Best practices include:

• Finding and supporting DSD champions (from different agencies/positions).
• A focus on collaboration and coordination is key.
• Hold regular meetings with all stakeholders to help in clearing up misunderstandings, aligning expectations, roles and responsibilities, and starting up activities.
• Incorporate monitoring and evaluation activities early to measure the outcomes of the DSD SI activities.
• Seek needed technical clarifications from Global Fund early on
• It is important to have TA providers that both know the country well and are locally known and respected (this facilitated initial acceptance).
• For future SI design, it’s useful to have an in-country coordinator.

“We expect that at the end of this funding cycle, the DSD SI would have influenced policy and practice across the global HIV portfolio resulting in the adoption, financing and implementation of various effective service delivery models that are tailored to the needs and preferences of persons at risk of HIV acquisition or on HIV treatment and which improve equitable access to HIV prevention, testing and treatment services for all.” Dr Obinna Onyekwena, HIV Advisor, The Global Fund

Common emerging themes

• Slow start up in most countries.  The TA contracting process and the involvement of many stakeholders make the start-up process and meetings unwieldy and are some of the causes for the delay. Ideally, the program's design and operationalization  needs to start much earlier, the aim being to align it with the main grant's processes.
• A large number of stakeholders, both within the DSD SI and in the broader DSD and HIVST space.
• Regular coordination at country level using existing coordination structures where possible (e.g. HIV technical working group) is crucial to overcome these challenges and is one of the key approaches that countries can use to maximize the impact of the DSD SI and of other DSD initiatives in country.
• Reconsider or redesign the approach in the future to reduce the number of parties involved in the process, leverage existing coordination mechanisms (e.g., the CQUIN learning network), increase the involvement of primary recipients in the design of the SIs and in selecting the specific catalytic activities that can support countries in adopting DSD as an HIV service delivery approach.
• It is important to recognize that some countries need other types of support (other than TA) to scale-up their HIV DSD service delivery approach.  For example, Cameroon and Guinea needed support for training, human resources and to update monitoring and evaluation systems. Earlier planning of a future SI alongside grant-making could ensure that these 'non-TA' activities are covered in the main grant.

Next steps The second phase of the evaluation will focus on in-depth case studies of the DSD SI implementation in Cameroon and Ghana. Ghana has shown the quickest progress and has an interesting mix of TA support — international and local TA with a strong local WHO presence and virtual engagement with SH:24. Cameroon has overcome a slow start to register significant progress and is leveraging previous experience with DSD initiatives begun prior to the DSD SI. Phase three will look more in-depth at coordination of DSD activities, both at the country and cross-country levels and explore the potential for closer collaboration with the CQUIN learning network.