The Technical Evaluation Reference Group has developed a position paper on health systems strengthening, in which it advances a number of recommendations. The Secretariat has been asked to prepare a workplan with timelines for implementing the recommendations. The workplan will be presented at the next meeting of the Strategy, Investment and Impact Committee, which is likely to happen in February or March 2016. This process will produce an enhanced approach to HSS, and will also feed into the development of the Global Fund 2017-2022 Strategy. Background Since its founding in 2002, the Global Fund recognized the key role that health systems strengthening plays in the fight against HIV, TB, and malaria. To date, the Fund has invested more than $2 billion into HSS, either through stand-alone HSS grants or HSS activities embedded in HIV, TB, and malaria grants. Support for HSS began with a narrow disease focus in the earliest funding rounds, and progressed to the concept of cross-cutting HSS to address broader health system issues that affect outcomes in all three diseases. The Ebola outbreak brought into sharp focus the importance of a strong, overarching system in which communities can effectively respond to emerging health threats. The experiences of countries affected by Ebola contributed to an understanding of how countries can be supported to strengthen their health systems. Meanwhile, with the introduction of the new funding model, the Global Fund revised its approach to HSS in an effort to optimize the impact of its investments. The new approach was outlined in the Global Fund 2012-2016 Strategy, and explained in a recent concept paper released by the Secretariat. The emphasis in the concept paper is on building resilient and sustainable systems of health. The paper outlines seven main approaches for building such systems, including providing support for national health strategies and integrated service delivery; strengthening community responses; involving communities in national decision-making; and tailoring investments to the specific needs of each country. The NFM has seen a significant increase (compared to the rounds-based system) in funding requests and approvals for cross-cutting HSS programming. However, reviews of the concept notes by the Technical Review Panel flagged large variability in the quality of HSS proposals (see GFO coverage here and here), specifically with respect to ensuring that the necessary support mechanisms and processes are operational at the country level. Thematic review In response, the TERG commissioned the Euro Health Group to conduct a thematic review in a dozen countries that have had some success in their health systems investments, and to identify lessons learned that could inform future Global Fund investments in this area. The review focused on four themes that had previously been identified as important factors influencing the quality of proposals and subsequent implementation. The four themes are listed below, along with a summary of the consultants’ major findings.

Coordination, alignment and harmonization. Strong government leadership in required to ensure that HSS activities are coordinated and aligned with national priorities. A lack of coordination of HSS investments leads to fragmentation and duplication.

Technical assistance. Even in countries that have had some success in strengthening their health systems, there is no systematic approach to identifying TA needs, assessing what TA is available for HSS, coordinating TA provision, and evaluating its quality. Well-coordinated TA is critical to mobilizing stakeholders to work together in building country capacity. A lack of a systematic approach to providing TA undermines the concept of cross-cutting HSS.

Funding mechanisms. Pooled funding and the use of joint donor financing mechanisms improve the coordination of HSS investments and reduces fragmentation and duplication.

Monitoring and evaluation. Systematic, rigorous evaluations can help reduce inefficiencies and improve the quality of programming.

In addition, the consultants said that the use of integrated concept notes, where countries combine HIV, TB, malaria and cross-cutting HSS requests under one application, leads to improved programmatic quality, increased efficiency and more impact. TERG recommendations Based on findings from the thematic review and other inputs, the TERG put forward a number of recommendations. Many of them are described below.

1. The Global Fund should take a more active role in efforts to promote universal health care. The principles of UHC are consistent with the work the Fund is doing with respect to both its disease-specific programming and its efforts to build resilient and sustainable systems for health. The Global Fund is well positioned to mobilize its global and bilateral health partners around this issue.

2. The Global Fund should also use its leverage to get partners to collaborate on harmonizing their various HSS investment guidance documents. This could also lead to harmonizing HSS funding application timeframes, review processes, and materials.

3. The Global Fund should build the capacity of its country teams to strengthen HSS. The teams play a critical role in supporting the country dialogue and concept note development processes. It makes sense, therefore, to ensure that country team members are well versed on issues related to health systems. Although the Secretariat has developed online training programs on HIV, TB, malaria, and HSS, their uptake has been low.

4. The Global Fund should maximize the use of strategic partnerships. This includes facilitating and supporting mechanisms at the country level to enable development partners to coordinate their activities so that they align with the national priorities. One way the Global Fund could work with partners is to identify technical implementers with well-established presence in key countries and recognized expertise in areas relevant to the Fund’s mandate, and develop contractual mechanisms to engage them in TA provision, either under the umbrella of the Fund’s current agreement with the World Health Organization, or through separate mechanisms.

5. The Global Fund should develop a policy on differentiated approaches to HSS investments in order to ensure that current guidance on such approaches is applied consistently.

6. The Global Fund should increase the support it provides countries to develop integrated concept notes.

7. The Global Fund should promote the use of the country dialogue process to maximize investments in HSS. When the Fund informed countries of their allocations, it provided a suggested split a for HIV, TB and malaria, but not for HSS. Since most disease programs are underfunded, countries are reluctant to take money away from the disease programs to support HSS. The Fund needs to more actively encourage countries to set-aside funding for HSS from the overall allocations.

8. The Global Fund should establish a mechanism for systematically evaluating HSS investments, something that has been sorely lacking. Consideration should be given to conducting these evaluations in conjunction with the national disease program reviews to best capture the broader outcomes and impact of health systems investments.

9. The Global Fund should consider other innovative approaches, such as exploring the feasibility of establishing an inter-agency HSS Coordination Task Force to serve as a mechanism for implementing some of the recommendations in the TERG report and to provide a corporate framework for HSS partners’ actions at the country level.

The workplan that the Secretariat is drafting will presumably be discussed at the next SIIC meeting and then modified based on the input from the committee. It is not clear whether the workplan itself will need to be approved by the Board. In any event, the new Strategy for 2017-2022 is expected to describe in general terms what the Fund’s approach to HSS will be going forward. The new Strategy is expected to be adopted at the next Board meeting on 27-28 April 2016. Editor’s Note: The two reports cited in this article – the thematic review conducted by the Euro Health Group and the TERG position paper – are not available on the Global Fund website. Both reports were prepared as inputs into the meeting of the SIIC in October 2015. The Secretariat told GFO that we could report on the contents of the reports but that there were no plans to make the reports public.