Innovative technical support to countries’ Global Fund COVID-19 mitigation proposals provides directions for future assistance

Author:

Arlette Campbell White, Anthony Kinghorn, Pierre-Corneille Namahoro and Marc Péchevis

Article Type:

Article Number: 4

UNAIDS support identifies implications and opportunities for Global Fund proposal development

ABSTRACT The Joint United Nations Programme for HIV/AIDS has extended its technical support from assisting countries to develop their HIV grant applications to providing support, both in-country and virtually, to develop national Global Fund COVID-19 Response Mechanism proposals. This article, the fifth in a series of several, discusses implications and opportunities arising from lessons learnt from peer-reviewed C19RM applications that could be applied to future grant development.

Background

In 2021, the Joint United Nations Programme for HIV/AIDS (UNAIDS) established an innovative technical support (TS) model to support countries preparing applications for the second phase of the Global Fund’s COVID-19 Response Mechanism (C19RM). It comprises in-country support to proposal development, an online Virtual Support Desk Mechanism, and a helpdesk to provide countries with tailored, long-distance technical support on request, as well as virtual peer reviews of draft applications.

In this article, the fifth in the Global Fund Observer’s series on C19RM experiences, the UNAIDS Technical Support Mechanism (TSM) peer review team and UN Joint Programme experts discuss implications and opportunities for technical support arising from lessons learned from peer-reviewed C19RM applications, to further strengthen future funding requests (FRs).

Eligible countries were invited to request their C19RM Full Funding Request during four submission windows in May, June, July and September 2021. Our earlier articles Innovative technical support to strengthen countries’ COVID-19 mitigation proposals to the Global Fund and Community-Based, Rights and Gender Interventions fail to feature strongly in Global Fund COVID-19 mitigation proposals), noted that 17 countries (now 18, with the inclusion of recently-reviewed Pakistan) have been peer-reviewed, four of them twice.

Implications for future technical support provision go beyond C19RM proposal development

We have already described the major factors that impacted the development of C19RM funding applications, such as short process timeline, new intervention areas, and application materials, lack of data, endorsement by and thus coordination with the national C19 response coordinating body, and no requirement to submit Gap Analyses or Performance Frameworks.

Hence, it was unsurprising that the peer reviews highlighted a number of common weaknesses in the draft applications which are likely to pose a few challenges at the C19RM grant-making and implementation stages. These challenges may also have direct consequences for effective Global Fund grant implementation.

Need to improve planning, prioritization, innovation, management, oversight

The following questions are applicable to most of the proposals reviewed:

• Have the strategies and implementation stages of these C19RM applications been planned with enough understanding, rigour, and detail to address C19RM obstacles and opportunities in practice?
• Are interventions suitably prioritized to respond effectively to this new pandemic and mitigate its impact on HIV, tuberculosis (TB), and malaria (HTM) programs by introducing adequate corrective and/or adaptation measures?
• Have applicants really seized the opportunities for introducing innovations, making the best use of new technologies rather than rolling out business as usual, when the new and evolving context makes it even more important than before to deliver services differently?
• Have the right management and oversight mechanisms been well thought through and planned?

It is likely that the responses to those questions will indicate that most countries need to prudently review and refine their plans, including implementation arrangements, to ensure a rapid start-up and rollout of their C19RM grants in order to protect disease investments, with a particular focus on those services most impacted by the pandemic. They should also strengthen systems and approaches that will enhance longer-term service performance, and limit the risk that the COVID response could undermine them. This also includes the importance of prioritizing key health systems strengthening (HSS) components, such as human resources for health and supply chain management, that have to be fit for purpose – especially when dealing with a pandemic.

There is also a risk that countries’ national responses have not fully appreciated what C19RM grant oversight means in terms of maximizing the benefits for HTM and the broader health system. Countries will have to carefully review and/or establish the right leadership and oversight and governance mechanisms to ensure that the COVID-19 response delivers the expected results. This is particularly important as many countries indicated that their mitigation measures to protect HTM were covered by previous grants, and it is unsure how complete and coordinated this synergy will be

Need to enhance the focus on specific thematic areas

Even in the stronger C19RM proposals, major gaps were observed in various thematic areas. These included: gender-based violence (GBV), community, human rights and gender (CRG), Differentiated Service Delivery (DSD), community-led monitoring, community-led responses, specific key and vulnerable populations’ (KVPs) needs, TB and sexual and reproductive health (SRH).

Therefore, one activity that would add value over the coming months at the country level would be to identify where the main thematic gaps are and determine how best to address them.

Need to disseminate and strengthen technological innovations (especially for KVPs and CRG), including peer learning between regions and countries

The Global Fund C19RM instructions clearly request applicants to look for alternative and new ways to provide essential services that are currently unable to function normally because of COVID-19, but also to identify mechanisms for optimizing results and value for money. But, as we noted previously, very few countries have taken advantage of technological innovations, especially when it comes to KVPs and CRG. In the next funding window(s), but also at grant-making and implementation stages, countries need to further explore and introduce new technologies for national programs to move from purely physical interventions to virtual ones, across all thematic areas.

Such virtual interventions and responses have already been deployed and documented in different regions (see Box), and knowledge of good practices and success factors is slowly growing. It is therefore important to disseminate that learning by enabling stronger collaboration between the Global Fund and its key technical partners (such as the President’s Fund for Emergency AIDS Relief (PEPFAR), UNAIDS, the World Health Organization (WHO), and other TS providers) in different regions. Countries could consider innovations that have been introduced in other countries in their region; but, also, in other regions where some countries may be way ahead of the curve. Countries can access available tools and/or scale up their implementation to tackle current challenges in (differentiated) service delivery and restore key services for KVPs.

Need to look for synergies with existing grants and across components

We previously mentioned the frequent lack of information about program disruption and even more so regarding how C19RM-requested funds complement domestic and other resources, despite the Global Fund request to provide details on the “impact of COVID-19 on the overall health system, including the impact on the continuity of services, particularly for key and vulnerable populations” and remembering that some countries already included aspects HTM mitigation using funds from earlier grants.

As C19RM grants should not be implemented in isolation from Global Fund and other partners’ grants (such as those from PEPFAR and COVAX immunization effort through Gavi), countries should judiciously review the relationship and linkages between the various grants and search for synergies during the grant-making and implementation phases (e.g., ensuring that M&E supports, rather than complicates, multiple programs), and address fundamental issues like supply chain management and capacity development. This may eventually also lead to a program revision of core Global Fund grants.

Establishing the right M&E mechanism and providing information for strategy and program refinement

Beyond the lack of data on COVID-19’s impact, and because the Global Fund does not require a Performance Framework at the FR stage, countries should work together with the Global Fund Country Teams to develop a framework with measurable indicators and targets to monitor C19RM grant implementation. This would also demonstrate how those new investments and adaptations succeed in mitigating COVID-19’s impact on diseases and the health system.

Another broad area countries should consider is the provision of information and data for refining strategies and programs going forwards. Some countries will be coping better with addressing COVID-19 than others who may be struggling with the ‘shifting sands’ of new implementation models and changing COVID-19 epidemiology, depending on whether vaccine programs are reaching the right beneficiaries. Countries will have to be aware of global best practices. They will also have to conduct ongoing needs assessments to ensure that the priorities remain the same or to be able to adjust interventions appropriately.

Integrated HSS, including civil society strengthening (CSS)

The C19RM proposals noticeably lacked an emphasis on HSS and CSS in particular. These are areas where UNAIDS, the Global Fund through its CRG Strategic Initiative, and other partners such as Frontline AIDS can support countries to consider how to incorporate C19RM interventions that strengthen program design, implementation, M&E, financing, and service delivery. The importance of communities in C19RM grants, emphasized by the Global Fund, means countries have to understand how to integrate public sector collaboration with civil society and community organizations in key areas of the responses to COVID and the three diseases. This integrated HSS approach could be discussed with key partners like PEPFAR to avoid any divergence or duplication of interventions and realize potential synergies and improved effectiveness across the whole health pyramid including the central, intermediary, and peripheral levels.

Opportunities for technical support and its implementation modalities

As previously discussed, most countries will still need to further develop, strengthen and refine their C19RM grants and national responses to tackle the COVID-19 pandemic and its impact on the diseases and health system. This raises new challenges, but also opportunities, for technical support partners (including the UNAIDS-TSM). These are:

 

Coordination of technical support strategies and roles

As we look at the way forward in resolving what might be some systemic challenges in mitigating COVID-19’s impact on HIV responses, there are some critical gaps that need to be discussed with other partners.

Clarify Global Fund plans for refining weaker C19RM and HIV/TB grant responses and Above Allocation awards, and addressing important gaps, e.g., underdeveloped civil society components

The Global Fund is currently taking stock of the C19RM applications and the existing HIV and TB grants to identify gaps (e.g., pandemic mitigation activities) and under-developed components such as M&E. How demanding will the Global Fund be at the grant-making and implementation stages in requiring countries to reprogram funds to address these issues, given the need for rapid responses? As one of the Global Fund’s main technical partners, UNAIDS will have to revisit and coordinate its role with the Global Fund and other partners. Together they will have to explore more ways of extending and targeting support to various countries, Country Coordination Mechanisms (CCMs), and Principal Recipients (PRs) to address the priority bottlenecks affecting approval and effective implementation of HIV programs.

Division of TS roles between partners

Deciding what kind of TS and when it is needed should be led by the country itself through its different mechanisms (including but not limited to the CCM) and forums such as the development partners/health donors’ regular meetings, the MOH itself, and so on. This is especially important when discussing COVID-19 and impact mitigation that goes hand in hand with health system strengthening and ensuring the rapid adaptability and resilience of health systems in the long run. Through an inclusive process, looking at the needs evidenced by data and performance, it is the national counterparts that should define roles and request the needed TS, depending on each partner’s role and competitive advantage at the country level. Some countries manage this very well; they request different TS from the various partners and TS provision is ultimately more successful because the country is leading the process. In this way, they not only ensure accountability for partners’ commitments but, most importantly, for implementation of the recommendations.

Plans for possible future C19RM applications (that could benefit from refined guidance and TS)

After Window 6 in mid-September, are there going to be future C19RM applications and, if this is the case, should UNAIDS systemize learning and the methodologies to support these applications? Not only in the program design process but also in program implementation providing more support to CCMs (and PRs).

Conclusion

The plethora of lessons learned and experiences gained from the Virtual Support Mechanism have provided practitioners with a wealth of information that should be built on to provide grant applicants with support for proposal development, grant-making, and grant implementation. How this learning is captured and disseminated still remains unclear. However, what is evident is that both technical partners, the Global Fund, and the countries it supports can build on these experiences so as not to lose the momentum, and apply them to regular grant applications and implementation.