The Global Fund has achieved generally positive results against its key performance indicator (KPI) targets, according to a report on strategic performance prepared for the Board meeting on 15-16 May.
The number of lives saved in 2017 by the Global Fund partnership was 5.1 million, the report said. This puts the Fund on track to meet the target of 29 million lives saved for the six-year duration of the Global Fund Strategy 2017-2022.
The report said that there was strong performance on Strategic Objective 2 (Build Resilient and Sustainable Systems for Health) and Strategic Objective 4 (Mobilize Increased Resources); and that there has been recent progress but also continuing challenges on Strategic Objective 3 (Promote and Protect Human Rights and Gender Equality).
Significant improvement is needed on incidence reduction, the report said. At current funding levels, and in the absence of sufficient progress, there is a risk of not meeting the target: a reduction in new infections/cases of 38% by the end of the Strategy 2017-2022. In 2017, the reduction was 6%. The report said that if recent trends continue, the expected decline by 2022 will reach only 21%. However, the Global Fund said, the target could still be reached if the Sixth Replenishment is successful.
The report said that the focus going forward should be on bending incidence curves down by accelerating new tools and strengthening the implementation of existing ones; supporting higher HIV prevention and treatment coverage; continuing to find missing TB cases; and improving vector control and case management for malaria.
Performance on grant operations and financial indicators has been good, the report said. Grants are being signed promptly; funding is aligned to needs; and, at 75%, absorption rates have already reached the 2022 target.
In the balance of this article, we report on what the performance report said concerning absorptive capacity; other key findings in areas such as human rights and the availability of health technologies; KPIs at risk of missing their targets; and other miscellaneous findings. We also provide information on a pilot project involving reporting country-level performance. Finally, there is a section at the end of the article on the format of the performance report.
The 75% absorption target is part of KPI 7b. In the performance report, the Global Fund provided additional information on this KPI. The Fund said that common assumptions about absorption are not always correct (see Figure 1).
Figure 1: Common assumptions regarding absorption
Source: Global Fund. GF/B41/14 Strategy Performance Reporting –– End 2018
The Fund said that there has been a general improvement in most countries, including in COEs (challenging operating environments), since the last performance report in November 2018. The region with the strongest improvement is West and Central Africa (11% increase in absorption).
The Fund said that in several regions there appear to be differences in absorption among the different types of implementers. Generally, absorption is higher for multilateral organizations, for civil society organizations (i.e. community, NGO) and for private sector implementers, compared to government implementers. However, this does not hold for all regions. In Africa and in MENA (Middle East and North Africa), civil society, private sector and government implementers absorb at similar levels. There is also a slightly better performance for sub-recipients (SRs) compared to principal recipients (PRs).
The report also said that absorption level and programmatic performance are not always aligned. The two are often not measured in the same way. For example, programmatic performance is generally measured at the national level, whereas absorption is based on Global Fund financing only. This can create a disconnect in countries where most of a given program is funded by other sources.
Other key findings
Human rights-related KPIs
KPI 9a –– Reduce human rights barriers to services
According to the performance report, in the 20 cohort countries where there is an initiative underway to implement comprehensive programs aimed at reducing human rights barriers to services:
- 18 countries have finalized baseline assessments. The assessments have informed programmatic recommendations and established a measurement framework against which progress will be tracked;
- In nine of the countries, multi-stakeholder meetings have been conducted, resulting in the establishment of working groups developing country-owned plans for a comprehensive response; and
- 17 countries incorporated matching funds into their Board approved-grants. In these countries, there has been a ten-fold increase in the level of human-rights investments.
Board Document GF/B41/14, “ Strategic Performance Reporting – End 2018,” like other documents prepared for the 15-16 May 2019 Board meeting, should be posted shortly at: www.theglobalfund.org/en/board/meetings/41.
Board-related documents are usually posted to the Global Fund’s website within two weeks of the meeting’s completion.
KPI 9b – Human rights and key populations in MICs
The report stated that whereas 3.4% of HIV grant budgets in middle-income countries (MICs) is invested in programs to remove human rights-related barriers (vs. a 2019 target of 2.9%), only 0.7% of TB grant budgets in selected high-burden MICs have similar investments (vs. a 2019 target of 2.0%).
The Global Fund said that two large grants in high-impact countries are still outstanding and are likely to impact results for this KPI. The Secretariat is providing extensive support to encourage increased investment in these grants.
KPI 9c – Human rights and key populations in transition countries
The report revealed that 47% of upper-middle-income (UMI) countries with approved grants have reported domestic investments in both key populations and human rights programs (vs. an end-2019 target of 100%). The report said that the target is aspirational and will not be met, due in part to the lack of co-financing requirements for human rights. The report noted, however, that 82% of UMI countries have reported domestic investments in key populations programs alone.
KPI 12a – Availability of health technologies
The report stated that the proportion of defined products with more than three suppliers meeting quality assurance requirements is 69% (vs. a target of 100% by 2019). The report said that low volumes of pediatric products presents challenges to maintain more than three suppliers. The Secretariat is planning to propose “a revised, realistic target” for KPI 12a in 2019.
KPIs at risk of not being on track to meet targets
KPI 2 – Service delivery
As of mid-2018, results were at risk of being off track for:
- Prevention of mother-to-child transmission (PMTCT) coverage;
- The proportion of people living with HIV (PLHIV) who know their status;
- The number of people living with both HIV and TB on antiretroviral therapy;
- The proportion of PLHIV on isoniazid preventive therapy (for TB); and
- The proportion of pregnant women on intermittent preventive therapy for malaria.
The Secretariat has conducted a deep-dive analysis to better understand root causes driving the gaps between strategy targets and projected results. Country teams are using country portfolio reviews to help identify the root causes.
KPI 5 – Key populations service coverage
As of mid-2018, the report said, 45% of countries are able to report on service coverage for key populations, vs. a target of 75% by end-2019. The report noted that another approximately 25% of countries are just slightly below the “able to report” threshold.
Support from the Secretariat is focused on countries currently listed as “potentially able to report” through measures such as: deploying technical assistance via the Communities, Rights, and Gender (CRG) Strategic Initiative (e.g. to support integration of community-based monitoring into key population reporting); and deploying technical assistance via the Data Strategic Initiative (e.g. to strengthen country key-population program monitoring systems, cascade analysis, testing yield analysis and prevention effectiveness analysis).
KPI 8 – Gender and age equality
The report stated that HIV incidence among adolescent girls and young women (AGYW) declined by 16% in 2017. If recent trends continue, the report said, only about 75% of the Strategy target (a decline of 58% by 2022) will be met. Efforts will need to be accelerated.
The main thrust of the Secretariat’s response is to focus its efforts on ensuring all cohort countries have a defined package of AGYW interventions and an M&E framework to measure coverage and outcomes. In addition, work is underway to improve quality and sustainability measures.
KPI 6c2 – Financial management
The report said that 13 countries (vs. a 2018 target of 16) have implemented required actions to meet defined financial-management systems standards for optimal absorption and portfolio management. The report stated that another three countries are close to the required level.
Other miscellaneous results
The performance report said that for the 2017-2019 allocation period to date:
- 36% of grants (and 30% of the funding) is being managed by community sector implementers, many of them local;
- About half of transition-preparedness components have completed a transition readiness assessment (TRA) or equivalent;
- 195 grants have been provided to community-based groups through the HER Voice Engagement Fund, up from 93 in mid-2018; and
- 43.0% of cohort countries provide results that are disaggregated by age and gender for all relevant indicators (vs. an end 2019 target of 50.0%) (GFO was unable to obtain more detailed information on the cohort countries by the time of publication.)
Country-level reporting pilot
The performance report revealed that the Global Fund is reporting some country-specific results on a pilot basis. It is doing so for KPIs for which the country-level data are (or will be) publicly sourced; and where the data are available and relevant to understanding KPI performance.
Traditionally, strategic performance reporting has been at a global level (or regional level where appropriate). Recently, however, the Secretariat has shared some country results profiles with the Board; and constituencies have requested more KPI country-specific analysis, both at country and grant level.
The Global Fund said that it wants to ensure that the pilot is not used to name and shame countries, to lower the level of Board discussions or to foster micromanagement.
According to the performance report, country-specific results that could be reported now include the following:
- Impact and service delivery (using partner or national data): Performance against impact targets (KPI 1); Gender and age equality (KPI 8); and Performance against service delivery targets (KPI 2);
- Data sourced from grant reporting: Fund utilization/absorptive capacity (KPI 7b); and RSSH: Results disaggregation (KPI 6e); and
- Corporate public data: Alignment of investment and need (KPI 3).
Results for additional KPIs could be available in future.
The Strategic Performance Reporting paper that was provided to the Board for its May meeting did not include any country-specific results. (GFO was unable to obtain more information on country-specific reporting by the time of publication, but will report further on this topic in a later edition.)
About the report format
The performance report, which is in the form of a slide deck, contains 53 slides. Performance results were presented in four main categories: funding; program design; implementation; and impact/results. There was also a section on the context for the three diseases; and a section on underperforming KPIs. An annex to the report contained detailed results by KPI.
This reporting format was first used for the May 2018 Board meeting, so this is the third report using this format. Many of the slides contain a lot of information, usually in bullet format, crammed into a small space. Of necessity, therefore, some of the information is rather cryptic.
Since the primary target audience consists of Board members and their delegations, this may well be a suitable format for them. However, these reports become public once the Board meeting is finished. The Global Fund does not currently produce a different version of the performance report for a wider audience (though the Strategy Committee has discussed the possibility of the Fund producing an annual progress report for stakeholders).
For the GFO, trying to write a summary of the performance reports for GFO based on documents in this format is challenging.
Board Document GF/B41/14, Strategic Performance Reporting – End 2018, should be available shortly at www.theglobalfund.org/en/board/meetings/41.