EARLY LESSONS FROM THE IMPLEMENTATION OF A STANDALONE HEALTH SYSTEM STRENGTHENING GRANT IN DEMOCRATIC REPUBLIC OF THE CONGO
Article Number: 7
How continuous implementation support enables simple, targeted solutions to health system strengthening challenges
ABSTRACT This article analyses the first findings of the support from BACKUP Health to the Democratic Republic of the Congo’s Global Fund health system strengthening grant. It shows that long-term support to the Principal Recipient helps to address both technical challenges in grant implementation and coordination, and positively affects the quality of interventions. Most importantly, it supports the country to conceptualize and prioritize the inclusion deep impact health system strengthening interventions in the next GF funding cycle. Those lessons should be shared between the countries and the pilot activities included as routine interventions to make the implementation easier and achieve a greater impact
Since its inception, the Global Fund has invested $9.4 billion in strengthening health systems and $4.9 billion of this is in the current cycle, which began in January 2021. For the first time in 2020, countries had been asked to identify a specific envelope for resilient and sustainable systems for health (RSSH) activities and to formulate a package of activities by system pillar.
The following diagram shows where HSS investments have been made under NFM2 and NFM3.
In 2020, the DRC decided to submit a request for standalone funding for an initial amount of $100 million, which was revised downwards and then revised upwards again with the addition of funding for the fight against COVID-19, for an amount of approximately $80 million.
This article looks at the challenges in implementing the RHSS grant. Specifically at how BACKUP Health in partnership with Aidspan in an approach funded by the UK’s Foreign and Commonwealth Development Office (FCDO), is attempting to address these challenges through targeted actions, deployment of simple tools, and support for change among system actors at the decentralized level. Indicators such as the percentage of annual plan executed, absorption rate, percentage of open advances have been set and are currently monitored. A mid-year review will be conducted in March 2023 to assess the progress, based on evidence-based information.
Challenges to RSSH grant implementation
Several recurring challenges are common to the implementation of HSS grants, particularly when they are managed by a Principal Recipient (PR) from the Ministry of Health.
Difficulty coordinating all stakeholders involved in health system at all levels
Coordination of HSS activities is complex because it involves central-level actors from departments that are not necessarily accustomed to working together and that do not report hierarchically to the management unit that manages Global Fund grants.
Based on the modules selected, the Sub-Recipients (SRs) are the Health Information Directorate, the Pharmaceutical Affairs and Drug Control Directorate, the Primary Health Care Directorate and the Laboratory Directorate. These departments do not collaborate regularly and are used to receiving direct support from partners according to their priorities. In the case of Global Fund grants, it is the PR that receives the funds and asks the Ministry’s departments to plan, request funds and justify the amounts spent. However, these Directorates are ill-equipped to ensure coordination, generally have little training in operational planning, and do not have the internal financial skills to manage the funds and ensure that procedures are followed. The lack of a hierarchical relationship with the Project Management Unit harms the accountability of these Directorates. To address these issues in some countries, PRs have decentralized staff to support the directorates and avoid so many delays.
Vertical coordination is also complex, as most HSS and disease grant activities are partly executed at the peripheral level. However, most countries in the Francophone African region are now in the process of administrative decentralization, which gives management autonomy to the regions/provinces in the administration of funds and the implementation of health services. The regions/provinces are therefore implementing partners, but they are rarely involved in regular dialogue with Global Fund actors, which considerably delays implementation.
With the support of Aidspan, the principal beneficiary’s HSS team, the Financial Management Support Unit (CAGF), conducted a diagnosis of the difficulties in planning and monitoring implementation. This revealed two major difficulties:
- The absence of a programmatic tool to plan the activities to be implemented during the semester, which would allow for the verification that the pace of implementation is in line with the forecasts.
- The lack of justification for incurred expenses and the accumulation of open advances of more than 90 days, which eventually become ineligible expenses that the country must reimburse, and which currently amount to several million dollars.
To address this problem, a dashboard has been developed that includes all HSS grant activities and that the SRs update on a weekly basis. A CAGF focal point checks weekly that the dashboards are up-to-date and that the open advances log is reviewed. Two indicators are monitored monthly:
- The percentage of planned activities implemented on time.
- The percentage of advances liquidated versus the proportion of advances older than 90 days.
Thanks to the fact that all the activities are implemented by the Ministry PR, with the participation of the Planning Directorate, this dashboard will be presented to the Secretary General for him to promote its launch throughout the country as the MOH planning tool for the 26 health provinces.
Cumbersome implementation procedures and contracting activities
The PR’s procedures occupy five manuals of about 200 pages each. In addition, the contracting arrangements are very cumbersome and the processes are lengthy, which explains the major delays in key activities such as the reproduction of data collection tools (registers, patient files and records), the start of the Service Availability and Readiness Assessment (SARA) survey on service accessibility, or the health development survey. In addition, the purchase of services, particularly technical assistance, is also problematic, which explains why several projects have not progressed.
In response to these bottlenecks, which considerably slow down implementation without necessarily guaranteeing risk-free grant management, a procedural review mission by the PR and stakeholders will begin mid-December. The review has two objectives:
- To simplify procedures, in order to clean up the manual and only retain mandatory information and guarantee proper anticipation and management of risk. In addition, discussions will take place regarding the adaptability of certain procedures to the implementation context, particularly in very remote areas, where invoices and justifications are difficult to obtain. The objective is to maintain risk management measures but propose procedures that can be applied by health zones and areas, without forcing them to ‘manufacture’ receipts.
- Produce materials to disseminate the procedures adapted to the required use and to the actors: Instead of five volumes, short booklets adapted to SR needs will be produced, as well as infographics and materials that are easy to use by actors who are not familiar with the Global Fund procedures and require simple and functional diagrams to avoid getting lost.
Procurement rules will also be reviewed to comply with the provisions of the country’s Public Procurement Law. Finally, experiments will be conducted to accelerate the decentralization of procurement, as the provincial directorates are already replicating their tools with funding from other donors. They should also be able to select local suppliers capable of providing internet connection and compose a catalog of suppliers without going through the central level, which delays them.
Lack of support at the decentralized level
Decentralization, and the creation of Provincial Health Divisions in 2012, has not had the adequate political support and resources to become effective. In the health sector, the Provincial Divisions have been given important prerogatives in the mobilization and management of finances, as well as in the supervision of health zones. However, the lack of support from technical and financial partners has led to a weakening of the provincial division heads and a blurring of technical and political responsibilities. The provincial approach, launched by the Global Fund in 2018, is a response providing support to two provinces on the following aspects:
- Annual planning of activities from the most peripheral to the central levels.
- Improved data quality for informed programmatic decision-making.
- Support for provincial health department leadership in mobilizing funds and in political and technical dialogue.
A review of this decentralization approach will be carried out by the MOH PR, with the support of GIZ and FDCO in February 2023, to share lessons learned with countries interested in this approach. Additionally, to improve the impact of the grant in the provinces, further activities have been conducted:
- Support for the provincial activities’ biannual review: to improve the analysis of the difficulties and foster a more analytical and participatory exchange in order to result more realistic recovery plans.
- Support for the development of annual operational plans to improve their quality, from the central health level to those of the provinces.
The multiplicity of technical and financial partners
Coordination of the technical and financial partners is an issue in the region’s countries because despite the donors’ good will and the efforts of the ministries, it seems impossible to align projects with the national health development plans and harmonize financing tools. As a result, it is the ministries, in particular the planning departments, that are trying with little success to coordinate all the support; and they pay a high price for this.
The DRC benefits from the support of some 40 technical and financial health sector partners, for amounts that exceed $1 billion annually. The coordination of all these actors is a major challenge in terms of alignment and complementarity, while the needs are great. It is currently difficult for the central level to control and coordinate all the partners’ processes and actions and this problem is also mirrored in the provincial directorates. Kinshasa province has 34 partners, North Kivu has 17, and despite the consultation frameworks created by the MOH, each partner finances according to its geographic and thematic priorities.
In order to improve the monitoring of partners’ financial commitments the MOH will launch a partner tracker in December. The tracker will show all partner investments by province, health zone, duration of projects, geographic coverage, and health domains. The Ministry has appointed a focal point in each provincial division, responsible for updating the tracker and supporting the provincial division head in defining the priorities based on epidemiological data. A semi-annual consolidation will allow the Secretary General to access the collated information and convene the partners once or twice a year through the National Health Sector Steering Committee and its counterpart at the provincial level. The idea is to eventually create basket funds where all the partners support the national strategic priorities, which are then implemented in the provinces.
This ‘pilot’ project has identified many areas to improve implementation, whether it be through programmatic and financial implementation management, the introduction of tools to facilitate SR management or in the provision of tools for the provinces to enable them to regain control over discussions with partners.
Many areas for improvement were also identified during the training workshops held with the eight provinces covered by the Global Fund resilient and sustainable systems for health (RSSH) grant. Their first request was for greater involvement in the country dialogue process and for their priorities and needs to be considered in future funding requests, which are usually planned at the central level. They have also asked for additional support in management training and supervision of lower levels, as well as in measuring the quality of their activities: integrated supervision, data monitoring meetings, biannual reviews, etc. All these activities, if properly conducted, will have a direct impact on the accessibility and quality of services offered to the population. And it is in these conditions that RSSH takes on its full meaning: it focuses on the patient and his or her needs and vulnerabilities in accessing services, instead of focusing on the health system.
This experiment constitutes a good example of a winning partnership between a support team and a national PR though a dynamic and constructive partnership. It is an example that should be replicated in other countries struggling to implement their HSS grants, no doubt for similar reasons, other RSSH actors such as Chad, Mali, Guinea Bissau have already expressed their interest. In the process of elaboration of the GC7 (NFM4) funding requests, these activities that boost the implementation of the RSSS activities should be included into the grant. It is worth the effort and the investment is reasonable compared to the amount of the grant. This assistance was somewhat neglected under NFM3 but should be included under GC7 to accelerate the achievement of results.