On 9 June, the Technical Review Panel (TRP) published its analysis of the first 45 funding requests for funding submitted over the last 2 months, based on three criteria: strategic focus, technical soundness and potential for impact. Its conclusions are similar to those already set out by the previous TRP analysis, recorded in a report analyzed by Aidspan in January 2020.
While the TRP acknowledges some progress in the funding requests for the next cycle, particularly in the areas of Health System Strengthening (HSS) and human rights, it indicated that there are still many shortcomings similar to those in the current one. However, these shortcomings are more concerning since the increase in allocations, from 4 to 140% over the current cycle, for some countries offers the opportunity to drastically scale up their interventions and to set targets that make a stronger impact on eliminating HIV, TB, and malaria.
The information for this article is drawn from the TRP report as well as from Aidspan’s discussions with consultants, government officials, and representatives of civil society organizations (CSOs) who were involved in drafting the funding requests. This article focuses on the challenges highlighted by the TRP, and seeks to put them into perspective with countries’ experiences in developing funding proposals, and the numerous constraints on country dialogues that have an impact on determining priorities that reflect a clear strategy.
The TRP report found that many funding requests lack strategic vision, and do not reflect sound choices in terms of intervention strategy, short and medium-term priorities, or a real sustainable vision.
This is despite the fact that, with regard to the disease components, 98% of requests are aligned with national strategic plans, and that, with regard to HSS, the Global Fund’s tools (the modular framework and technical briefings provided) strongly guide the choices and arguments for setting priorities. The TRP observed that the requests do not explain how or why tradeoffs (to select the activities that are to be prioritized and financed) are made, nor motivate why specific scenarios are selected. Activities are always short-term and based on the length of the grant, and requests do not explain how the investments will be sustained, particularly for financing health personnel but also “pilot” approaches developed outside the health system.
With regard to HSS, the TRP report points out that the absence of a national HSS roadmap prevents a consolidated vision of priorities for each country, and does not clearly present the Global Fund investments in the health donor ecosystem. Furthermore, the TRP noted that investments to strengthen the system are spread across different requests, submission windows or time periods. This makes it difficult to analyze proposed investments.
Beyond the strategic aspects, the TRP observed that requests are not supported by investment cases, which would help put the cost-effectiveness of each approach and its sustainability into perspective. The TRP emphasized that this weakens the technical soundness of requests. It also noted that HSS grant applications continue to favor opportunistic investments, which aim to support interventions rather than strengthen the system in the long term.
A needs analysis at each level of the cascade for HIV and TB, as well as differentiated programming aligned to each treatment target for HIV, was not included in many notes. Plans to scale up programs, in order to make the elimination of the three diseases more possible, were also missing. These technical shortcomings naturally raise questions, for all the committed stakeholders involved in the process, regarding whether these technical discussions are taking place; are WHO, UNAIDS, Roll Back Malaria (RBM) and other partners’ technical notes and guidelines being consulted and guiding the work? Some Country Coordinating Mechanisms (CCMs), who are responsible for writing funding requests and submitting them to the Global Fund, admit to relying entirely on consultants and Technical and Financial Partners (TFPs) to ensure the technical quality of the notes. Other stakeholders, with whom Aidspan has spoken, reported that at times conflicting agendas of many stakeholders make discussions difficult and do not encourage objective choices. Finally, according to some consultants, there is a lack of time and space for these technical discussions: this is visible in the “lessons learned from the current cycle” insert, which is interpreted differently in different countries and is generally poorly filled out. Some requests identify very general lessons that are not specific enough, or explain what will be done in the next round, and others discuss performance but not the lessons learned.
The potential for impact
The TRP welcomed the inclusion of an insert on cost-effectiveness analysis. However, according to our sources, this insert is generally not filled out satisfactorily. Many describe much of the same activities: purchase of medical products through the Wambo.org online procurement platform to obtain favorable negotiated rates, integration of HIV/TB activities with Reproductive, Maternal, Newborn and Child Health (RMNCH) activities, or the use of GeneXpert machines for HIV and TB programs. Few of the notes discuss possible intervention choices complete with their assumptions, investment cases and expected impacts to explain why they favor one intervention over another. The funding requests describe activities with immediate outcomes, without indicators of progress or a strategy for sustainability.
To remedy this situation, the TRP has recommended adopting a methodology that describes the “theory of change” (TOC) developed for each program. This TOC would set milestones and progress indicators and identify the changes sought in the short, medium and long term. This methodology is particularly recommended for development of diseases programs, but difficult to implement in the country dialogue process.
A few thoughts to explain the continuing inadequacies
The modular framework has become an end in itself and not a tool
Some stakeholders admit that they fill in the form using the modular framework as a guide for the proposed activities. The preliminary phase of holding brainstorming workshops to share lessons learned, successes and failures in terms of impact, often does not take place and these fundamental analyses are ignored when determining what the investment priorities should be.
Moreover, the requests show inconsistent use of the modular framework: the majority follow it, but some propose activities that are not included in the framework, or reorganize its content. For example, the community system activities are split between three modules: the one on human resources for health, the module on service delivery, and the module on community system strengthening, which doesn’t allow a comprehensive vision of the community system. For many, the modular framework becomes a kind of “menu” from which they pick and choose; they tick the boxes to follow the proposed documents, without necessarily being guided by a clear and holistic strategy. Rather than being taken for what it is – a catalogue of possible options, at best a source of inspiration – the modular framework is often used literally, without any attempt to adapt the different proposed activities to the countries' contexts, and without justification of their choice of one activity over another. Unfortunately, not all activities listed in the modular framework are relevant to all countries and epidemiological situations.
Thinking long-term for 3-year cycles: a contradictory injunction
The TRP has emphasized the lack of sequenced planning, which makes it possible to put short-term investments into perspective and discuss its impact and sustainability over the medium and long term. However, the Global Fund’s cyclical three-year grant period makes this approach difficult for long term planning. Consider the following scenario: the first year is the start-up year with challenges in implementation and set up, especially if the country changes its implementation arrangements (with the selection of new Principal Recipients and Sub-Recipients); the second year is mostly when full implementation takes place; and in the third year, while continuing the implementation, trying to catch up on delayed activities, and reprogramming for saved or unused funds as the grant cycle is ending, countries are beginning to prepare the funding request for the next cycle. This leaves only 12 to 16 months, which is too short a time to focus on implementing activities, analyzing successes and failures, readjusting programs and measuring impact.
Some countries have worked around this. Benin, for example, has a roadmap to strengthen the system over six years, and has spread Global Fund financing over two cycles. In Mali, the reform of the health system launched in 2019 combines various health donors, which allows for a unified medium-term vision. However, in many countries, this vision is not yet clear, and despite updated National Strategic Plans before or during the preparation of the funding requests, the top priorities do not appear obvious. In the case of HSS, the absence of country roadmaps and the difficulty to get health donors to jointly plan investments with the national stakeholders, hamper this process.
Strengthening the system while ensuring results in the fight against the three diseases
The TRP report notes that the link between system-strengthening activities and the expected impact on outcomes for the three diseases is weak. Admittedly this intellectual exercise is difficult, especially if the focus is on the patient, not on the delivery of health services. Indeed, current WHO recommendations tend to favor an analysis centered on the needs of the individual, for accessible, equitable and quality care. The activities proposed in the HSS modules seek to strengthen the health system pillars (which in itself should be revised to give priority to a vision based on the patient and his or her needs) without having particularly immediate and visible effects on the three diseases. If they were to have any, they would run the risk of calling into question the very idea of HSS, which is intended to be cross-cutting. There is therefore a real intellectual difficulty in combining the two. The TRP and Global Fund recommendations should offer more guidance to countries.
Competing emergencies: building on gains while scaling up
The TRP report is generally critical of the lack of ambition in the targets for testing and treating, and this is one of the reasons for another iteration of the funding requests. However, it should be noted that the results achieved are already at risk, given the undetectable low viral load rates and declining retention rates after only 12 months for the HIV, particularly in West and Central Africa. There are a few studies comparing different retention strategies (using SMSs, home visits, self-support groups and ART groups), but these can still be improved, and they require significant resources.
Countries need to set ambitious targets for detecting and treating new cases, while recognizing that the current system and the capacity of CSOs, an essential link in the follow-up of patients, are limited. Strengthening these two aspects takes time and is not easily accommodated in a three-year cycle. The fastest successes are most often outside the health system, to avoid pitfalls and burdens, have well-trained and adequately remunerated human resources, and put in place an adequate performance measurement system. This is probably one of the reasons why UN agencies and International Principal Recipients set up parallel supply and distribution chains, or why they recruit qualified staff and pay, train and retain them to implement activities of overloaded Ministry of Health Personnel without building capacity of existing staff (sometimes at the expense of ministries).
Is it realistic to have competing priorities, i.e. sustaining gains in testing and treatment while also scaling up patient screening and treatment? For some countries that are still fragile, should the 2021–2023 cycle aim to strengthen the system and its actors, leading to real acceleration in 2024?