The Global Fund Strategy 2012-2016 remains as valid now as it was when it was developed in 2011 and its principles and directions should continue to guide the Fund in the coming years. This was a central conclusion of the Strategic Review 2015, carried out by the Technical Evaluation Reference Group. A report on the review was provided to the Board at its meeting on 16-17 November.
Despite this very positive assessment, the TERG noted several areas where improvements are required. Below, we provide highlights:
DIFFERENTIATION. The TERG said that although good progress has been made in transforming how the Global Fund functions – in particular, increasing allocations for high impact countries – this progress is being hindered by the continued application of what it termed “undifferentiated policies and procedures.” (This refers to having the same policies and procedures for all countries regardless of the risk or the size of the portfolios.) The TERG said that these policies and procedures created unnecessarily high transaction costs for the country teams in the Secretariat and for the countries themselves.
HUMAN RIGHTS AND GENDER. The TERG noted that the Secretariat has been instrumental in supporting a strong emphasis on key populations and a rights-based approach, but that its efforts have not yet been fully translated into programming within countries. The TERG said that gender analysis “remains especially weak.” It said gender analysis in concept notes “is often reduced to looking at how the epidemics have a different effect on women and men, rather than examining the social and cultural factors that make women (or men) more or less vulnerable to each particular disease.”
KEY PERFORMANCE INDICATORS. The TERG said that although a range of measures have been instituted by the Global Fund to monitor and improve its performance, concerns have been expressed about the value of the present set of KPIs for tracking Secretariat performance. (See separate article in this issue on KPIs.)
The TERG said that the KPIs are central to the Secretariat being able to demonstrate results. It said that there are many technical issues concerning the current KPIs that need to be resolved. But, beyond that, the TERG said, understanding changes in an indicator requires significant understanding of the context. “When corporate KPIs are intended for use by the Board as much as by management, as in the Global Fund, problems arise when Board members lack the same level of contextual understanding [as management].”
INCENTIVE FUNDING AND THE UQD REGISTER. With respect to the new funding model, the TERG found that the upfront allocation to countries based on GNI per capita and burden of disease has successfully ensured that Global Fund investments are better targeted to countries with the greatest potential for impact. The TERG also found that the strategic objectives of increasing the predictability and flexibility of funding allocations have been largely achieved, and have been welcomed by implementing countries and partners. “Less successful,” the TERG said, “has been the introduction of incentive funding and use of the unfunded quality demand register.”
Incentive funding was intended to motivate countries to submit more ambitious requests. The TERG said that according to country stakeholders and the Technical Review Panel, this did not happen and that incentive funding has led to increased transaction costs. The TERG recommended that incentive funding be transformed into a fund to reward performance.
The TERG said that the UQD register would have little effect “as the Global Fund itself is unlikely to have sufficient funds to invest in additional activities and little evidence was found that other donors were stepping up to fill the gap.”
COUNTRY OWNERSHIP. The TERG found that Global Fund processes do not yet appear to be fully aligned with, and supportive of, country-driven planning processes or national systems. In some cases, the TERG said, it appears to function the other way around. “Some countries appear to have been overly influenced by NFM requirements and made revisions to their national strategic plans prior to concept note development in order to assure greater alignment with the Global Fund.” In addition, the TERG said, only a few countries proposed that their grants be aligned with and managed through national health systems or that the grants progressively work towards integrating current parallel systems into overall national health systems and structures.
SUSTAINABILITY AND TRANSITIONS. The TERG said that sustainability and transition planning remain poorly operationalized within many countries. It recommended that the Global Fund broaden the concept of sustainability beyond the concerns around transition. It also recommended that the Secretariat change it focus from its current analyzing and piloting mode to one of actually supporting countries.
The TERG concluded that there has been significant impact and that the level of funding is an important factor in this impact. The TERG pointed to positive trends of declining incidence and mortality from 2000 to 2013 at an aggregate level across the 27 focus countries. Additionally, increasing trends were seen in the numbers of lives saved in all three diseases during this time period.
OTHER. Other findings of the evaluation included the following:
- Establishing formal partnerships agreements at the global level has strengthened global coordination of technical support and has improved the provision of short-term TS, but “more attention is now needed to ensure that these agreements are working effectively at country level and that there is systematic engagement by in-country partners to improve program implementation and sustainability.”
- There has been inadequate support for either mobilizing resources from the private sector or ensuring that non-governmental (e.g. civil society) contributions to the health sector can be sustained.
- More focus is also required on countries that are transitioning between income groups and on how to encourage them to contribute to their own financing gaps.
- Gaps in financial expenditure data in many countries make it difficult to track what funds have expended on national programs.
The TERG presented several recommendations for the next strategy, based on the the findings in the Strategic Review 2015. They included the following:
- Stay the course: Continue the current strategic objectives and directions without major changes.
- Let countries lead: Give greater priority to strengthening national ownership.
- Use differentiated approaches in the different country contexts to reduce transaction costs for both the countries and Secretariat staff.
- Seize opportunities to advance human rights and gender equality.
- Buy into universal health coverage: Promote more integrated, health systems-oriented investments to enhance Global Fund’s contribution to national universal health coverage priorities.
- Invest in improving data quality.
The Board acknowledged the results and recommendations of the Strategic Review 2015; asked the Secretariat to provide a response to the TERG’s recommendations; and asked the Secretariat to consider the TERG’s recommendations as it prepares the final Strategy.
The Strategic Review 2015, Board Document GF-B34-10, should be available shortly at www.theglobalfund.org/en/board/meetings/34.