Despite some delays, steady progress has been made in implementing the many activities related to the Global Fund’s strategy on building resilient and sustainable systems for health. Some challenges have been encountered, especially in operationalizing strategic initiatives. Building resilient and sustainable systems for health is the second of four objectives in the Global Fund Strategy 2017-2022.
A report presented at the Board meeting on 14-15 November in Geneva, Switzerland, provided an update on implementation of activities under the objectives and sub-objectives of the Strategy. For each sub-objective, the report described the progress achieved to date, as well as key challenges and risks, and future plans. In addition, the report identified the key performance indicator (KPI) tied to each sub-objective. In most cases, full reporting on the 2017-2022 KPI Framework will not be available until early 2018.
In an article in GFO 325, we provided a general overview of progress to date related to the first strategic objective, “Maximize impact against the diseases.” In this article, we summarize the progress that has been made under the seven sub-objectives of Strategic Objective #2 (Build resilient and sustainable systems for health):
- Strengthen community responses and systems.
- Support reproductive, women’s, children’s and adolescent health and platforms for integrated service delivery.
- Strengthen global and in-country procurement and supply chain systems.
- Leverage critical investments in human resources for health (HRH).
- Strengthen data systems for health and countries’ capacities for analysis and use.
- Strengthen and align to robust national health strategies and national disease-specific strategic plans.
- Strengthen financial management and oversight.
For space reasons, we have had to be selective about which examples we include.
(See separate article in this issue for a report on progress made against Strategic Objective #3 – Promote and Protect Human Rights and Gender Equality.)
Strengthen community responses and systems
The Community, Rights and Gender Strategic Initiative (CRG-SI) has received requests for technical assistance (TA) to implement systematic and strategic community responses to deliver services and foster accountability – by, for example, building the capacity of community representatives so that they can better perform their roles and accurately represent the demands of their constituencies. The TA program provides support to civil society and community organizations to meaningfully engage in Global Fund processes, including country dialogue, funding request development, grant-making and grant implementation. Thus far, the CRG-TA program has provided support to Kenya, Indonesia, Mozambique, Cambodia, Lao, Vietnam, Thailand, Myanmar and Southern Africa. Support is currently being provided in Sierra Leone, Nepal and Cambodia.
In addition, the Global Fund is expanding a research project to document and provide technical assistance to support community-based monitoring (CBM) in 5-10 countries (not listed in the report). An agreement has been reached with CBM implementers in the Democratic Republic of Congo and Sierra Leone to refine and scale up current CBM programming. In Sierra Leone, for example, the Global Fund has provided technical support to build the capacity of community organizations to provide feedback on the quality of services to help catalyze problem solving at the local level.
This combined operations research and technical assistance work will be conducted in the fourth quarter of 2017. There is a desire to broaden the scope of the work and increase the number of countries included in the initiative. However, this is still under discussion due to budget constraints.
Lastly, after a delayed recruitment process to hire a new advisor on community systems and responses, the position has now been filled and work is underway to define mechanisms to efficiently channel funds to community-based organizations. Given the current focus on grant-making, this work will not be completed until the first quarter of 2018.
Support reproductive, women’s, children’s and adolescent health
The Liverpool School of Tropical Medicine has been commissioned by the Global Fund to lead a three-year study on program quality improvement pertaining to the integration of HIV, TB and malaria into ante-natal care (ANC) and post-natal care (PNC) in a minimum of six countries (including Togo, Niger, Ghana and Afghanistan).
In Togo, memoranda of understanding have been signed with principal recipients and the University of Lomé. Core programmatic tools have been translated and adapted into national quality improvement standards; demonstration workshops have been held; and baseline data collection has begun. In Niger, the service agreement is in the process of being finalized. In Ghana, it is expected that activities will be completed by the end of 2017. It was anticipated that by September, facility assessments, ANC/PNC demonstration workshops and quality improvement standards would have been completed. Lastly, in Afghanistan, the budget and implementation package for the Phase 1 of the project were still being negotiated.
Some countries are experiencing challenges allotting funding for Phase 2 of the project from their upcoming 2018-2020 allocation due to diminished grant allocations. Efforts are underway to address this through budget efficiencies – e.g. lowering unit costs, and better utilizing existing initiatives and resources – to free up money for this project.
Strengthen global and in-country procurement and supply chain systems
Internal risk assessments conducted by the Global Fund have identified weaknesses in supply chain processes. To address this, the Fund launched a new supply chain initiative in 2016 which includes a supply chain strategy; and, in 2017, the Fund developed a two-year supply chain implementation plan. The initiative calls for in-depth diagnostics in 12 high-risk countries to be conducted by the end of the year; and working with government and private sector partners to implement supply chain transformation projects. (See GFO article.)
At the time of the report, diagnostics in Cameroon and Burkina Faso were nearing completion and work in Liberia was well underway. The remaining nine diagnostics were at various stages of implementation. The transformation projects are expected to start in 2018, once the diagnostics are completed and the high-level partnerships are solidified. It is worth noting that finding the political will to take on the supply chain diagnostics and transformation project has been a challenge. The Global Fund is trying to address this by including a broad range of key partners and stakeholders to foster a greater sense of ownership.
Leverage critical investments in human resources for health
Three countries – Sierra Leone, Guinea and Afghanistan – had successfully applied for matching funds for human resources for health and had moved into the grant-making stage at the time of the report. Other applicants for matching funds for human resources for health include Ethiopia (applied in Window 3), Liberia (will apply in the fourth quarter) and Benin (will combine its application with its RSSH grant in January 2018). The requests include activities such as piloting support for more integrated community health services, including integrated training packages; capacity building and health worker retention; and improving workforce management systems.
A key challenge is ensuring that technical support is available during both the development of the grant applications and implementation of the ensuing grants.
Strengthen data systems for health and countries’ capacities for analysis and use
Twenty health facility assessments (HFAs) and data quality reviews (DQRs) are scheduled in high impact and core countries. Of these, six have been completed, another eight will be done before the end of the year, and the remaining six will be finalized in the first quarter of 2018. According to a slide presentation on the Global Fund’s revised approach to program and data quality assessment, HFAs should be conducted every two years to assess the quality of services delivered at health facilities according to a number of metrics, including availability, readiness and quality of care. Data quality reviews are typically done annually; however, they can be completed in conjunction with the HFAs because the results of one inform the other. The slide presentation is available here.
In addition, the Global Fund has completed a framework on the use of data “for action and improvement.” The high-level framework is currently being translated into detailed guidance that will be used to strengthen in-country reviews and dialogues to improve programming.
Lastly, a human rights, gender and TB key populations monitoring and evaluation framework has been finalized. UNICEF has started work on the community service delivery portion, which will be completed in the first quarter of next year. This work experienced some delays due to internal reorganization at UNICEF.
Strengthen and align to robust national health strategies and national strategic plans
Through the Impact Through Partnership (ITP) project, an in-country review and dialogue component is being designed to inform the development of national disease strategies as well as program and grant management. The ITP is a vehicle to leverage country-level partnerships to drive efforts to maximize the impact of the response to the diseases by overcoming bottlenecks in implementation.
The Global Fund has set aside $14 million for catalytic investments under the strategic initiative “Resilient and Sustainable Systems for Health: Technical Support, South to South, Peer Review and Learning.” This includes funding for technical partners to support integrated planning for the three diseases.
Interestingly, the Global Fund notes that a potential conflict may arise with countries due to the perception that providing support for the development of strategic plans could lead to the providers having undue influence over the outcomes of the process.
Strengthen financial management and oversight
The Global Fund is developing comprehensive action plans to implement country- or donor-harmonized financial management systems for its grants. For example, India’s Ministry of Health now tracks expenditures in 10 states using an integrated financial management information system. In Sierra Leone, the Ministry of Health and Sanitation has fully operationalized the use of a shared service/donor harmonized unit (use of a single information system, finance manual, personnel, etc.) to financially manage donor investments. The work is still in early stages in Liberia, where it is part of the International Health Partnership for Universal Health Coverage.
One activity highlighted in the report cuts across the entire objective: development of an RSSH Dashboard. After requests were received from country and regional managers, and in collaboration with partners, 82 country profiles have been drafted and disseminated. The Global Fund is looking at how to move the tool to a better IT system and ensure linkages with other initiatives, though the further development and maintenance of the dashboard will depend on the availability of external funding.
Board document GF-B38-11 “Update on the Implementation of the 2017-2022 Strategy,” should be available shortly at www.theglobalfund.org/en/board/meetings/38. See separate article in this issue for a report on progress made against Strategic Objective #3 (Promote and Protect Human Rights and Gender Equality).