According to the Technical Review Panel (TRP), integration, both across the three diseases as well as more broadly to other health services such as RMNCAH (reproductive, maternal, newborn, child and adolescent health) –– a priority articulated in the Global Fund Strategy 2017–2022 –– is lacking in funding requests. “While there are some efforts at integration in areas where there has been considerable global attention, such as in TB/HIV, TB and HIV disease programs still tend to operate through vertically implemented activities,” the TRP stated.
The TRP made these comments in a report it released recently on RSSH investments in the 2017–2019 allocation period. The report contained a section on integrated service delivery (ISD). This article summarizes the TRP’s findings with respect to ISD-related gaps in funding requests as well as the TRP’s recommendations on how applicants, the Global Fund and partners can address these gaps.
(See our article on the full report in GFO 348; and our article on the section of the report on human resources for health elsewhere in this issue.)
For its report, the TRP analyzed 50 funding requests from Windows 1–5.
The TRP said that the ISD modules included in the funding requests it sampled generally represented about 15% of the country’s total RSSH request. However, proposed interventions were generally poorly defined, the TRP noted. Applicants tend to view the ISD module as a “catch-all” in which they include interventions that have no relevance to integration. For example, the TRP said, interventions such as “lab investments” and “service delivery infrastructure” are placed within the ISD module, even though the proposed interventions don’t contribute towards integration of systems.
TB/HIV integration continues to pose problems, the TRP observed. When funding requests included activities to strengthen integration, the focus was often limited to a few activities. Only 3% of the budgets in the TB, HIV and TB/HIV requests sampled by the TRP included specific investments for TB/HIV integration. Nevertheless, the TRP stated, there were a number of examples showing increasing attention to important areas of integrated TB/HIV service delivery –– for example, TB screening in HIV clinics and HIV testing in TB clinics, as well as attention to key populations such as prisoners.
One positive example of integration, the TRP said, was a funding request that included several innovative TB interventions to maximize impact, such as incorporation of TB services into maternal child health care; TB collaboration with non-communicable diseases; and programs for migrants and childhood TB.
The TRP said that although the funding requests included initiatives related to RMNCAH –– such as expanding prevention of mother to child transmission (PMTCT) programs –– the requests did not “systematically include outcomes beyond the target disease or maximize the opportunities the RMNCAH platform offers.”
While there were some funding requests that promoted iCCM (integrated community case management), and IMCI (integrated management of childhood illness), the TRP said, the requests generally supported pilot phases; interventions were rarely brought to scale.
There is a lack of appropriate indicators to track activities related to integration, the TRP stated. In the RSSH modular framework, there are two coverage indicators for integration of service delivery –– (a) number of health facilities per 100,000 population; and (b) number of outpatient visits per person per year. Neither one is reflective of integration, the TRP said; in addition, there are few outcome indicators tied to improvements in RMNCAH.
In general, the TRP remarked, the funding requests it sampled did not aim to improve integration with general health services beyond the three diseases.
How the Global Fund channels financing and the guidance it gives to applicants may also create barriers to integration of health systems, the TRP observed. For example, it said, in Window 5, the Global Fund’s request for proposals for multi-country TB interventions among refugees in Eastern Africa did not encourage applicants to program TB services as an integral part of the package of basic health services provided to refugees in camps.
In addition, although the Global Fund is supportive of integrating health systems, it predominantly tracks investment outcomes by disease program, the TRP noted. Most donors follow a similar approach. “This approach is in conflict with the objective of moving towards universal health coverage,” the TRP stated.
The TRP noted the following additional integration issues:
- Although integration of TB, malaria and HIV diseases surveillance into DHIS2 is progressing, parallel disease-specific data systems and surveys still exist.
- There are still incentive and remuneration schemes specific to projects and diseases.
- Integration of community systems and responses is lacking.
Commodities continue to be procured by single-disease programs.