The Global Fund to Fight AIDS, Tuberculosis and Malaria, in collaboration with the German development agency GIZ’s Back-up Initiative, and the Heidelberg Institute of Global Health (HIGH), trained representatives of Kenya, Nigeria, Uganda, and Zambia in grant writing for Resilient and Sustainable Systems for Health (RSSH).
To “Build Resilient and Sustainable Systems for Health” is one of the Global Fund's four strategic objectives. This training comes as the Global Fund Secretariat implements the first action point of its RSSH Roadmap which is “to strengthen RSSH capacity and voice in the country dialogue process.” Since introducing the New Funding Model in 2014, the Global Fund has focused 27% of its investments, about 5.8 billion, towards health systems. Those RSSH investments are direct investments in countries national health systems, e.g. building or renovating warehouses to store health commodities, and investments in disease programs with spillover effects on systems performance like purchasing laboratory equipment and training laboratory personnel for quality assurance that benefits the whole health system.
Participants in the training were representatives of CCMs, civil society, State and non-State Principal Recipients (PRs), Ministries of Health (including HIV, TB, Malaria and health system program managers), and partners. Aidspan participated in the meeting as an observer.
Training aimed to strengthen in-country dialogue
The trainers were Drs Olaf Horstick and Revati Phalkey from the Heidelberg Institute of Global Health. The training aimed to strengthen in-country dialogue by equipping key in-country stakeholders with the knowledge and instruments to be able to:
- Clearly understand the new Global Fund approach to RSSH and how this new approach could be expressed in a funding request
- Provide a coherent overview of what countries can do differently in this 2020-2022 RSSH grant, compared to previous ones
- Strengthen the ability of participants to identify the main challenges within the health system
- Strengthen the ability of participants to design high-impact RSSH interventions in the identified priority areas
The process for the Global Fund's current funding model involves the following steps. First, the Global Fund allocates funds to eligible countries for a three-year funding cycle. Countries receive an allocation letter with a total allocation and a suggested distribution of that total amount across the three diseases of HIV, TB and Malaria. RHSS does not have a separate budget allocation; it is supposed to be funded from the allocations for HIV, TB and malaria. The Global Fund encourages countries to either include RHSS activities within a disease grant or to present a stand-alone RHSS grant funding request.
The Country Coordinating Mechanism (CCM) develops and submits a funding request, “which is the plan for how the country would use the allocated funds if approved,” according to the Global Fund website. The funding requests are first reviewed by the Global Fund Secretariat, then sent to the TRP for evaluation. Upon successful evaluation by the TRP, the Board approves the proposal for funding. The proposal then goes to the grant-making stage, where the Global Fund Secretariat and the PR agree on details of the budget and activities. The last step is the signature of the grant contract.
The new approach for RSSH requests entails that countries identify the main challenges within their national health systems that impede the achievement of disease-specific goals; and conversely, the challenges in disease programs which strengthening the health system and multi-sectoral approach could resolve. This two-way identification first requires an effective and inclusive country dialogue where all voices are heard. Then a situation analysis, a selection of priority issues, the appropriate interventions, and the cost of those interventions need to be made explicit.
Investments in RSSH should improve the HIV, TB and malaria program outcomes
George Shakarishvili from the RSSH team in the Global Fund Secretariat explained the Global Fund’s new approach to RSSH: RSSH should not be seen as another vertical program but rather as an element in the service of the AIDS, TB, malaria and other primary health care.
Figure 1: Resilient and Sustainable Systems for Health in the service of the three diseases
Source: Global Fund RSSH department
The RISE model and systems-thinking
Dr. Phalkey recommended that participants apply the RISE model in their approach to RSSH. The RISE model emphasizes four elements: Results, Innovation, Systems-thinking and Equity.
- Measure and evaluate Results, outcomes robustly
- Use Innovative approaches and evaluate them properly
- Move from short-term support thinking to strategic System-thinking including the private sector
- Equity: Reach the poorest of the poor, the communities
She added that the main message from the training is to encourage the participants to “adopt a systems-thinking approach to diagnosing issues in Health System Strengthening and mapping pathways to RSSH.”
Experiences shared during the training
Participants discussed how they currently fund RSSH activities, conduct situation analyses, and choose priorities. Below we describe a few highlights of the discussions.
The Global Fund 2020-2022 allocation letters sent to countries in December 2019 indicate a suggested split of the allocation amongst the three diseases but is silent on how to fund RSSH activities. Countries are expected to fund RSSH activities from grants for the three diseases. All four countries in the training acknowledged that this situation creates their first challenge: though all stakeholders agree on the importance of the RSSH, disease programs are reluctant to see their available funds decreased for the benefit of RSSH, when those disease programs still have funding gaps. Dr. Joseph Kibachio, who represented the Permanent Secretary of Kenya’s Ministry of Health shared his country’s experience: Kenya deducts 12.3% from all the disease grants to fund RSSH activities.
Christopher Chikatula, the executive secretary of Zambia’s CCM, stated that the writers of their grants use a SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis model for their country’s situational analysis. Syson Namangada from Uganda’s CCM explained that her country relies heavily on the National Strategic Plan for health, which is usually drawn-up every five-year with broad consultation of stakeholders for important information and statistics used for their situation analysis. Margaret Shelleng from Nigeria explained that in addition to the NSP, her country uses the results of the country dialogue, whose process has improved over time: “Instead of a meeting with more than 100 people in one room,” Nigeria’s CCM now conducts several smaller meetings where it can better collect stakeholders’ views.
Participants also discussed issues of prioritization among competing RHSS priorities . Community responses and systems are weak in these countries despite their potential to improve grant performance and health outcomes. Strengthening them competes with another priority which is to strengthen Human Resources for Health like training or hiring more nurses for health facilities.
The trainers suggested that countries use a recognized model for the situational analysis and gave a few examples of models that they can use and reference for the publications. Participants received documents, including the TRP review guidance tool, they can use to conduct their analyses, determine their priorities and select their interventions.
Mr. Shakarishvili reminded the participants of the difference between system support and system strengthening. System support consists of short-term recurrent expenditures to make the system functional to effectively deliver HIV, TB, malaria, or other services. A top-up allowance for health workers is a health-system support. In contrast, system strengthening consists of expenditures with the potential to sustainably improve the system’s performance in the medium and even long-term. Improving procurement and supply-chain for health commodities is an example of health system strengthening. The Global Fund prefers to lean towards system strengthening instead of system support.
The trainers took participants through a process of identifying high-impact interventions within their chosen national priority areas from the planning, the design of interventions to address the priority areas, and the identification of necessary resources and tools.
During the training, participants raised RSSH topics that fundamentally impact the grants. Some of those topics are implementation arrangements, low integration of some RSSH activities in the disease programs in order to increase the impact of those interventions, considerable funding for international NGOs overhead and other management fees contrasting with limited funding for the same items for local NGOs, limited involvement of African universities and research institutions in the grant writing, design, implementation, evaluation, and other related research.
At the end of the two-day training, organizers asked for participants’ feedback. This feedback would help improve future trainings as this training was the first organized on this topic.
All participants acknowledged the usefulness of the training and the fact that they will use their new knowledge to improve their upcoming funding requests. Prof Mokuolu Olugbenga from the Federal Ministry of Health of Nigeria said “ the [TRP guidance tool] has provided a very useful guide focusing on RSSH. It will help with efficiency and time management as well.”
Participants emphasized that they have few opportunities for frank discussion and collaborations between RSSH experts and disease programs’ representatives. All participants overwhelmingly supported the idea advanced by one of them, to scale up such workshops and encourage senior-level policy-makers’ participation. Participants suggested that organizers also invite core writers of proposal requests to the next similar training. To improve efficiency, those core writers should come with their existing drafts of funding requests so as to improve them as the training progresses. Others suggested that the trainings last at least three days to accommodate practical writing time and more sharing.
These types of contributions reinforced the view of Eva Schoening, from the GIZ Back-Up Initiative, who said, “this training allowed representatives […] to exchange relevant context-specific experiences and to benefit from a South-to-South learning approach.”
Editor’s note: The ‘RSSH Roadmap’ document is not publicly available on the Global Fund’s website.
- 'Building Resilient and Sustainable Systems for Health (RSSH) Information Note' (23 August 2019)
- ‘Everybody’s Business: Strengthening health systems to improve health outcomes – WHO’s framework for action’ (2007).