7. FEATURE
15 Apr 2020
The COVID-19 crisis highlights the critical importance of health systems

GIZ BACKUP Health is a global program, implemented on behalf of the German Federal Ministry of Economic Cooperation and Development (BMZ), which supports recipient countries in their partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria. GIZ BACKUP Health, the Global Fund, and the Heidelberg Institute of Global Health organized a training session for five African countries that are planning to submit their requests for funding to the Global Fund in May and August 2020. However, because of the COVID-19 pandemic, only three countries, Mozambique, South Africa, and Tanzania, participated in the training, which took place in Cape Town in South Africa on 10-11 March 2020. The Global Fund has subsequently modified its submission deadlines, offering six deadlines instead of the original three in 2020, to compensate for difficulties countries are experiencing as a result of the coronavirus pandemic in preparing their funding requests.

The training aimed to strengthen each country’s capacity to leverage health-sector investments to build resilient and sustainable systems for health (RSSH) while addressing disease-control needs at the local, national, and regional levels.

For this article, we conducted a joint interview with representatives of the three institutions that organized the training. They are Eva Schoening, a technical advisor for health system strengthening at GIZ BACKUP Health; George Shakarishvili, a senior advisor in the health system-strengthening team at the Global Fund; and Olaf Horstick, an associate professor at the Heidelberg Institute of Global Health. We also obtained a copy of the training report, which has not yet been published.

Highlights of the training

This training is the second on health system strengthening organized by the Global Fund, GIZ BACKUP Health, and the Heidelberg Institute of Global Health, and has benefitted from the lessons learned during the first one. (Aidspan participated in the first training, which took place in Nairobi, Kenya, in December 2019). The December training had participants from four African countries: Kenya, Nigeria, Uganda, and Zambia.

The trainers used a participatory approach: they presented different theories and encouraged participants to discuss and share their country’s experience. Participants were representatives of various stakeholders and grant implementers, such as country coordinating mechanisms (CCMs), the health ministries’ HIV, TB and malaria control program managers, civil society organizations, and communities of people living with HIV or affected by TB or malaria. Interestingly, planning departments of the ministries of health of these countries were invited as well as consultants who are helping countries write funding requests for the 2020-2022 Global Fund allocation cycle. This broader inclusion was the implementation of a suggestion made during the first meeting in Nairobi. Countries’ planning departments generally have a more comprehensive view of the national health system than the different disease program managers do. As Heidelberg’s Olaf Horstick said, there was a “better composition of the country delegation” than in the first training.

On day one, the training participants highlighted the importance of systems-thinking approaches as opposed to project or program-thinking, in the diagnosis of challenges facing the health systems and the interventions to address those challenges. Those challenges fall under one of the eight thematic areas of the Global Fund RSSH framework. These eight thematic areas include community involvement and laboratory strengthening, in addition to the six other building blocks that compose the World Health Organization health systems framework. This comment concurs with the findings of the Technical Review Panel (TRP) of the Global Fund, which evaluates the funding requests. In its review of RSSH investments in the 2017-2019 funding cycle, the TRP deplored the fact that the RSSH grants tend to fund system support instead of system strengthening. For instance, the RSSH grants fund inputs such as cars to monitor grant implementation or on-the-job training sessions for health personnel instead of funding the development of standard operating procedures for laboratory systems or pre-service training for health personnel.

On day two, the trainers presented theoretical frameworks for priority setting and led fruitful discussions on the topic. The presentation focused on 1) situational analysis, 2) how to set priorities and select interventions using exercises, and 3) implementation planning. Then the participants discussed how they have chosen their countries’ priorities in the past and how they can implement the new knowledge for the upcoming funding request submissions.

At the end of day two, participants evaluated the workshop. All indicated their appreciation of the participatory approach; the majority affirmed that they had learned a lot from the other countries that were represented. Participants indicated that the two-day duration was not long enough to explore fully different aspects of the topic. They suggested at least a three-day training session to accommodate more discussion and practical exercises. Only five or six people represented each country in a multi-country training session. As a result the organizers have decided to explore the possibility of holding these training sessions in-country so that a broader range of national stakeholders would be able to participate.

COVID-19 affected the training and underscored the importance of health systems

Initially, the training was planned for five countries. But representatives of Sierra Leone and Lesotho could not participate because of the increasing spread of COVID-19 caused by the novel coronavirus, SARS-CoV-2, and recent related travel restrictions. Besides interfering with planned trainings and meetings, the COVID-19 pandemic has wreaked havoc on health systems in many high-income countries, creating great apprehension in countries with much fewer resources, including those that took part in the training.

Acknowledging the rapid global spread of COVID-19 and the devastation it is causing, the Global Fund Secretariat has announced that recipient countries can redeploy underutilized assets, repurpose grant savings, reprogram funding from existing grants, and use up to 5% of their grants to fight COVID-19. (See separate article in this edition on further decisions taken by the Global Fund Board on April 9, to increase the additional resources available to assist countries in their management of COVID-19.)

During the interview, representatives of the workshop’s organizing institutions discussed the way forward. Eva Schoening explained that GIZ BACKUP Health would consider supporting partner countries with pandemic-preparedness measures, in close cooperation with its counterpart, France’s 5% Initiative.  Similar to GIZ BACKUP Health, the 5% Initiative is a project of Expertise France, an agency of the French Ministry of Foreign Affairs, which offers technical assistance to countries in their partnership with the Global Fund. The collaboration between GIZ BACKUP Health and the 5% Initiative aims to provide RSSH-related training and other technical assistance to more countries, especially French-speaking ones. This collaboration would have a longer-term perspective beyond the upcoming funding request.

In the words of George Shakarishvili, a crisis such as that of COVID-19 makes a “clear statement about the importance of health systems.”

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