According to the Global Fund's Technical Review Panel (TRP), performance frameworks included in proposals submitted to the Fund continue to be inadequate. This is one of the observations contained in the "Report of the Technical Review Panel and the Secretariat on Round 9 Proposals," a document that was submitted to the recent Global Fund Board meeting in Addis Ababa.
The performance framework is that part of the proposal that outlines what the proposal sets out to achieve and how progress will be measured. For the most part, the TRP said, performance frameworks that it reviewed focus too much on process and output indicators, and do not contain appropriate outcome and impact indicators. The TRP added that performance frameworks often fail to include indicators to measure the quality of interventions. The TRP recommended that more detailed guidance be provided to applicants as part of future proposal guidelines, and that the Secretariat support the development of rigorous performance frameworks during grant negotiations.
In the "Report of the Technical Review Panel and the Secretariat on Round 9 Proposals," the TRP made a number of observations concerning the strengths and weaknesses of the proposals. The TRP also made several recommendations regarding how to address some of the weaknesses it identified.
This article provides a summary of the TRP's comments. It is divided into three sections:
- Technical Content of Proposals: General
- Technical Content of Proposals: Specific Disease Components and HSS
- The Applications and Review Process
TECHNICAL CONTENT OF PROPOSALS: GENERAL
Coherence and quality of proposals.The TRP said that many proposals do not contain a clear situational analysis and that, as a result, the TRP frequently had difficulty finding a link between the proposal narrative, budget and work plan. This is exacerbated, the TRP said, when poor quality budgets and performance frameworks are presented. The TRP recommended that the Secretariat clearly communicate to applicants the importance of having proposal narratives that are well aligned and consistent with submitted budgets and work plans.
Evidence-based interventions.The TRP observed that the strategies included in many proposals were not "evidence-based" - that is, did not provide evidence that the proposed interventions work or that they are consistent with or responding to what the actual needs are. This problem particularly arose with behaviour change communication (BCC) interventions for the three diseases, and with the combined use of indoor residual spraying (IRS) and long-lasting insecticide nets (LLINs) for malaria. The TRP recommended that applicants ensure that their strategies are evidence-based; and that where the evidence base is insufficient, applicants undertake an evaluation of proposed interventions, or conduct operational research on small-scale pilot interventions before going to scale.
Value for money.The TRP said that, generally speaking, proposals do not adequately demonstrate cost-effectiveness. The TRP recommended that the proposal form and guidelines explicitly ask for such information.
Human rights.The TRP noted that proposals that targeted vulnerable groups often did not provide information on relevant laws (e.g., criminalization of intravenous drug use and homosexuality) that could affect the proposed interventions. The TRP said that it is crucial to have this information in order to assess the soundness, feasibility and sustainability of the proposed interventions.
Gender.The TRP said that, as in past rounds, proposals for Round 9 mentioned gender and used appropriate terminology, but did not, for the most part, include a serious situational analysis or attempt to develop strategies to address gender inequality issues. The TRP recommended that the Global Fund's partners provide guidance and technical assistance to applicants in order to adequately address gender issues in future proposals.
Implementation strategy.The TRP said that many proposals lacked detailed information on the proposed implementation strategy. This made it harder for the TRP to assess the feasibility of the proposal. The TRP recommended that the proposal form and guidelines be revised to explicitly draw out this type of information.
Complementarity.The TRP found that many Round 9 proposals failed to demonstrate links with existing Global Fund grants and other donor funding. The TRP recommended that the proposal form and guidelines explicitly request applicants to demonstrate complementarity and additionality.
Absorptive capacity.The TRP said that it was concerned about the lack of absorptive capacity in some countries, in particular when a country has many ongoing grants, Global Fund or otherwise; and that this was particularly apparent when countries were funded for Round 8 and were again requesting funds for Round 9 for the same disease component.
TECHNICAL CONTENT OF PROPOSALS: SPECIFIC DISEASE COMPONENTS AND HSS
HIV.The TRP noted that HIV components are the least likely of the three disease components to be recommended for funding. The TRP said that, in general, "the quality of prevention strategies in HIV proposals is lacking. Many applicants did not elaborate how prevention strategies would be evaluated and what mechanisms would be used to ensure the quality and appropriateness of these."
The TRP said that it continues to be concerned that international best practice guidelines regarding infant replacement feeding are not being communicated at the country level. The TRP "reaffirmed" its Round 8 recommendation that partners provide in-country HIV programme managers with short, clear recommendations regarding when replacement formula may be appropriate, and that the Secretariat ensure that clear guidance is provided to future applicants.
The TRP noted that TB/HIV co-infection and collaborative activities are not systematically addressed in all HIV (and TB) proposals. The TRP said that applicants should clearly describe such activities in their proposals even when Global Fund money is not being requested, and that, should they chose not to do so, applicants should provide compelling reasons as to why not.
Tuberculosis.The TRP noted that Round 9 proposals did not always clearly describe proposed strategies, or their subsequent monitoring and evaluation, for advocacy, communication and social mobilisation (ACSM), practical approach to lung health (PAL), and infection control (IC). The TRP also noted that the rationale for, and demonstration of cost-effectiveness of, tuberculosis prevalence surveys in proposals is sometimes weak.
Malaria.The TRP welcomed the inclusion in several Round 9 proposals of an evaluation of mosquito resistance to insecticide. The TRP recommended that applicants build on the results of resistance surveys in order to design a management plan on insecticide resistance; and that applicants consider including measures of mosquito behaviour in the presence of insecticides to guide strategy selection and implementation.
The TRP applauded the fact that all proposals dealing with case management included a diagnostic component, and noted that some proposals were even ahead of the WHO recommendations in this respect.
The TRP said that a general lack of understanding of pre-elimination strategies resulted in some countries proposing a "cocktail" of interventions that were not always appropriate, given their local epidemiological context. ("Pre-elimination" is one of the four phases of malaria eradication. The four phases are control, pre-elimination, elimination and prevention of reintroduction.) The TRP recommended that Global Fund partners and the Roll Back Malaria Harmonization Working Group develop more guidance on the pre-elimination concept and on appropriate strategies in different contexts.
The TRP said that an "overall misunderstanding of the UN Secretary General call for universal access to malaria control interventions led some countries to request blanket coverage of all malaria control interventions" without due consideration of the epidemiology. The TRP recommended that applicants base any integrated vector management (IVM) strategy on local evidence of its effectiveness, in particular with regard to the additional benefit of having several interventions for the same target. The TRP said that this also applies to the concurrent universal use of long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) at country level.
The TRP said that some Round 9 malaria proposals included the use of pesticides to control mosquito larvae as a strategy without having demonstrated its effectiveness in the local context.
Health systems strengthening (HSS).The TRP found that there is a general lack of understanding among applicants regarding the difference between HSS interventions which should be included in the disease-specific sections and those that ought to be included in an HSS cross-cutting section.
The TRP noted that many applicants are requesting a "shopping list" of all theoretical HSS needs, without giving thought to longer-term HSS programmatic planning and expected impact. The TRP said that HSS submissions must be clearly presented as being auxiliary to, and flowing from, a national health strategy, while at the same time demonstrating how they help to address the three diseases. The TRP said that health sector reform leadership and governance issues were often inadequately addressed in proposals. Finally, the TRP said that the current health systems strengthening section of the proposal form is not satisfactory and could be improved.
THE APPLICATIONS AND REVIEW PROCESSES
Proposal form and guidelines.The TRP observed that some proposals are very long and exceed the requested page limits and that, despite the screening conducted by the Global Fund Secretariat, some proposals are incomplete and lack significant information. The TRP recommended that the Secretariat either more strongly emphasize to applicants the importance of staying within the allotted page limits, or adopt an automated proposal form which does not allow additional information beyond established page limits, or both. The TRP also recommended that the Secretariat screen out incomplete proposals based on pre-defined criteria.
Eligibility.Although the Global Fund requires that proposals from lower-middle- and upper-middle-income countries focus on poor or vulnerable populations, the TRP said that many proposals did not clearly demonstrate this focus. The TRP recommended that the Round 10 proposal form and guidelines highlight this eligibility requirement, and that applicants be requested to describe in detail how their proposal focuses on poor or vulnerable populations.
Regional proposals.The TRP said that the four recommended Round 9 regional proposals clearly demonstrated the added value of a multi-country or regional approach, but that this was not the case with most of the other eight regional proposals. With the latter proposals, the TRP said, the rationale for the specific countries collectively presenting a proposal was often unclear. The TRP also questioned the relevance of including service delivery interventions in regional proposals, on the grounds that they may contribute to the creation of parallel structures (i.e., at both regional and national levels).
The TRP recommended that applicants more clearly describe the expected added value of a multi-country or regional approach, as well as justify the selection of countries (e.g., based on epidemiological or strategic considerations). The TRP said that in many cases, single-country applicants failed to acknowledge their parallel inclusion in a regional proposal, and that it was evident that CCMs are not undertaking a full analysis of regional proposals when they endorse them. Finally, the TRP recommended that the regional proposal forms and guidelines be reviewed in order to avoid duplication and fragmentation, as well as ensure consistency, with national and sub-national proposals.
Financial analysis.The TRP noted that for the first time in Round 9, financial analysis support was provided routinely for the TRP's review of proposals whose lifetime budgets exceeded $100 million, and that such support was also available to the TRP for ad-hoc requests. The TRP recommended that in future, financial analysis support be provided for all proposals, regardless of the size of the budget, that the financial analysis be undertaken prior to the TRP review meeting, and that on-hand support also be provided during the meeting, as required.
Grant Performance Reports (GPRs).The TRP said that it uses the GPRs as the main source of programmatic and financial data for existing Global Fund grants, but that because separate reports are prepared for each grant, GPRs do not provide a holistic view of all the Global Fund grants in a particular country for a particular disease. The TRP added that there is a significant variability in the quality, completeness and relevance of the GPRs, and that they tend to provide more financial information than programmatic information. The TRP recommended that the GPRs be revamped to provide a more holistic view, and that the Global Fund Secretariat continue to improve the quality and content of GPRs and ensure that they include enhanced programmatic and quantitative information.
Language.The TRP recommended that countries be allowed to submit proposals in Portuguese, in addition to the six U.N. official languages.
The"Report of the Technical Review Panel and the Secretariat on Round 9 Proposals" should shortly be available at www.theglobalfund.org/en/board/meetings/twentieth/documents.