More needs to be done to promote the inclusion of operational and implementation research (OR/IR) initiatives in funding requests to the Global Fund. The Secretariat, technical partners and countries all have a role to play in making this happen.

This was the central message of a situational analysis of OR/IR and the Global Fund conducted by researchers affiliated with the Swiss Tropical and Public Health Institute; the University of Basel, Switzerland; and the Special Programme for Research and Training in Tropical Diseases at the World Health Organization. A report on their research was published recently in the journal Globalization and Health.

The goal of the research was to deepen the understanding of the extent to which OR/IR activities are included in Global Fund grants, and of the factors that influence this. Several methods were used, including a review of relevant documents; a review of grant proposals in six countries – Congo DR, Ethiopia, Zimbabwe, India, Indonesia and Myanmar; interviews with the fund portfolio managers or the country teams in each country; and interviews with Global Fund Secretariat staff and in-country key informants from different stakeholder groups.

The situational analysis focused on malaria and TB; HIV was excluded.

The researchers said that a number of proven standard interventions for controlling diseases in low- and middle-income countries exist – for example, large-scale distribution of insecticide-treated bed nets and ambulatory treatment of TB. However, they said, the effective implementation of these interventions requires adapting to specific contexts, which is where OR/IR comes in.

The Global Fund began promoting the inclusion of OR/IR in the programs it supports in 2008, when guidance documents and toolkits were developed. Subsequently, however, according to the researchers, attention to OR/IR waned and, today, the extent to which countries currently request Global Fund support for this research “remains unclear.”

Under the new funding model, the Global Fund provided guidelines on proven priority interventions eligible for support in its Applicant Handbook. However, the researchers said, there is hardly any reference to OR/IR – or to the role research may play in addressing context-specific implementation problems – in the handbook.

The researchers said that they observed considerable variations from one country to another and between programs with regards to need, demand, absorption capacity and funding for OR/IR. Although OR/IR was mentioned in more than 90% of the 49 grant proposals reviewed for this study, most references were to epidemiological and behavioral studies, the researchers said. One-third of the references were too broad to be categorized. And there was only one mention of a national research agenda.

Efforts to disseminate OR/IR findings were generally weak, the researchers said, and the Global Fund does not maintain a central OR/IR database.

The study identified perceived barriers to applying for OR/IR funding. They included limited overall funding; lack of a well-defined research agenda; lack of research capacity; and limited involvement of academia during concept note development.

Key informants told the researchers that it was often not clear to stakeholders whether the Global Fund was really interested in funding OR/IR. In addition, the study found that the inclusion of OR/IR in proposals and budgets is usually not actively promoted by the Global Fund.

The key informants interviewed for this study generally agreed that earmarking a fixed percentage of the budget for OR/IR was not a solution. Nevertheless, they said, more budget flexibility would encourage countries to apply for more OR/IR. For instance, it was repeatedly suggested that an appropriate amount should be reserved in the budget to cover emerging OR/IR needs, thus eliminating the need for formal budget re-allocations.

Recommendations

The researchers advanced several recommendations aimed at the Global Fund Secretariat, technical partners and countries. With respect to the Secretariat, the researchers recommended:

• that the Global Fund provide specific guidance on inclusion of OR/IR in funding requests and grant budgets;
• that the Global Fund ensure the necessary flexibility to fund small-scale OR/IR studies identified only after grant signing; and
• that the Global Fund create an inventory of OR/IR studies supported by the Fund.

The researchers recommended that technical partners promote and actively support the inclusion of OR/IR in country health strategies, strategic development plans and guidance documents.

Finally, the researchers recommended that countries:

• increase awareness of the importance of OR/IR within national disease control efforts;
• include more OR/IR in funding requests;
• strengthen capacities to coordinate research; develop research agendas; and plan, conduct and oversee OR/IR; and
• disseminate OR/IR findings to relevant stakeholders in order to influence policy and improve program performance.

According to the researchers, the Global Fund is expected to issue more specific guidance on the conditions under which it supports OR/IR.