Stakeholders’ views on the zero draft of the Global Fund Strategy Narrative
Article Number: 3
A promising start but a long way to reach the finish line
ABSTRACT The Strategy Committee meeting to be held during the first week of October will cover many topics but possibly none as important as the zero draft of the Strategy Narrative, which it will have to consider for recommendation to the Board. This article looks at the viewpoints of almost 20 groups of stakeholders on that draft Strategy Narrative and presents a summary of their views.
Prior to the Strategy Committee (SC) meetings to be held virtually between 5, 6, and 15 October, it is expected that the Global Fund stakeholders will have broad consultations with their members in advance and give feedback on the Global Fund Strategy. Undoubtedly the most important 75 minutes of the Committee’s meetings will be on this zero draft Strategy Narrative and the SC’s recommendation to the Board.
All the stakeholders congratulated the Secretariat on a very strong draft and appreciated the tremendous amount of work that has brought together a wide variety of inputs. On the whole, it was felt that this Strategy Narrative is a good reflection of the many discussions which have taken place over the past 18 months, including those during the Partnership Forums, as well as covering critical challenges and priorities identified during consultations.
However, most viewpoints also felt that the Narrative was woolly and vague, and did not go far enough in clearly articulating the details of the directions expressed. Many felt that the Strategy’s intended audience was unclear and that this needed to be defined before the next draft.
This article summarizes the overall views expressed by stakeholders. The Box below shows just a few of the many different perspectives stakeholders had of the same document.
|A Bird’s Eye View – Multiple descriptions of the draft Strategy Narrative
A lot to welcome Need for a more innovative, precise, and short document
Well-structured Lack of strategic language that helps visualize the key messages
Promising start Jargonistic
Technical Specialist-oriented, not user friendly
Comprehensive – but perhaps not implementable
Rich on detail Overly-detailed but not enough details where it matters
Ambitious Needs streamlining, currently a shopping list
Extensive process Repetitive
Clearly defined Room for refinements
Strengthening the Strategy Narrative
One viewpoint was that the Narrative would benefit from a clearer articulation nearer the beginning about the changed context for global health and for the Global Fund today, compared to five years ago, to help set the stage for the next set of objectives. This would include bringing forward the language and related table describing what is different compared to the current Strategy as the main structure within which to frame the narrative. Moreover, several felt that more clarity was needed where the Strategy was informed by the lessons learned through the many evaluations, audits, reviews, and in-depth reviews of the existing Strategy and current operations.
Most contributors, while complementing the rigor of the draft, felt that its length and detail (in some places too much and in others not enough) make it harder to understand (see our article First Look: The New Global Fund Strategy Narrative). They suggested that a standalone executive summary would be helpful.
Other overarching comments included the need for the Strategy to explicitly reflect implementation plans and a monitoring and evaluation (M&E) framework.
How is this Strategy different from the current one?
While many of us appreciated the intention of this section, the overarching view seems to be that it needed to be even bolder. Even though there is some effort in articulating what will be different, the Strategy Narrative is still trying to be ‘all things for all people’. It aims to focus on HIV, TB and malaria (HTM), but then still tries to cater to the interests of all parties.
To develop a more persuasive case on what is going to be different in this Strategy compared to the last, the Narrative needs to be more articulate about the underlying changes in the way the Global Fund operates that will be needed to deliver on the Strategy’s goal and objectives. This would require the Strategy to demonstrate greater agility and tractability in grant management systems to enable ongoing, rapid adaptation to innovations or emerging data. It would also need to reflect a more differentiated approach to risk management throughout and across the grant cycle.
The need for a Theory of Change to help with monitoring and evaluation
There are five ‘strategic’ (an overused word, as why would anyone design a non-strategic objective?!) objectives (including the one ‘evolving’ objective) and 42 sub-objectives in the current draft Narrative. Normally, each of these sub-objectives would need to have indicators for measuring how well the Strategy is being implemented. The current structure of the Strategy Narrative will make effective M&E much more challenging, and highlights the fact that the Strategy Narrative is not yet ‘strategic enough’.
Most importantly, the Narrative should lay out the next steps, including a promise to translate the Strategy into a Theory(s) of Change (TOC) that expresses specific pathways, risks, dependencies, and assumptions (e.g., matters outside the Global Fund’s control) that help articulate specifically what each partner must (or must not) do and that can serve as the basis for a comprehensive M&E framework for tracking progress.
Bringing in a TOC would showcase how these different, disparate Strategy areas could work towards achieving the Global Fund’s ultimate goal to focus attention on those areas that are most critical to invest in, as well as what areas others in the partnership could/should be taking responsibility for. The M&E framework could then build evaluation not only around a future strategy results framework but also around testing the TOC and its underlying assumptions
Primary goal: to end HIV, TB and malaria
Some partners wanted to see more of an approach that framed the three diseases within universal health coverage (UHC) and that the Global Fund’s objectives should ultimately contribute to achieving UHC, including strengthening pandemic preparedness and response (PPR).
Others felt that each of the disease sections could benefit from greater prioritization and Vale for Money (VfM). To distinguish more clearly what is within the remit of Global Fund, these sections could focus more on how grant-making and management can unite around the national strategic plans (NSPs) that guide disease programs and situate them within wider health planning and financing systems. As is well known from partner experience and the Prospective Country Evaluations (PCE), NSPs are frequently weak regarding their technical quality, prioritization, transparency, and especially in their inclusivity of and response to communities.
The heightened emphasis on incidence reduction, while generally supported, was found to have as many differences as there are commonalities in what this means for the three diseases.
Many partners felt that the section on the primary goal of ending HTM lacked much-needed specificity. In terms of ‘addressing structural barriers to HTM outcomes’, some stakeholders recommended further elaboration of the different and specific barriers faced by different marginalized and vulnerable groups such as women and girls, adolescents, displaced people and refugees, and people with disabilities among others, to ensure effective differentiated approaches to help different groups overcome their specific barriers.
More controversially, instead of the focus on ‘addressing the structural barriers to HTM outcomes’, a set of constituents proposed its replacement with a narrative that placed a primary priority on educating and strengthening actions to eliminate HIV and KVP related stigma, discriminatory laws, policies, and practices ― given that, they said, the legislative and policy changes to reduce HIV and KVP related stigma, discrimination, criminalization, other barriers, and inequities and uphold the rights of PLHIV and KVPs, may be the ultimate objective of the Strategy.
Stakeholders applauded the greater and much-needed emphasis on prevention but felt that the draft could be more rigorous in the prioritization of interventions with clear impact and effectiveness. This is a particular priority for many of the proposed community interventions and will require more political engagement by the Fund since the common barrier to their implementation is political resistance.
The various statements on the relationship between HIV interventions and health systems (including service integration, social contracting, and community systems strengthening [CSS]) could be strengthened by focusing more on how they will deliver impact and VfM in relation to HIV incidence and mortality outcomes. Frankly, stakeholders asserted, the Global Fund must stop funding HIV prevention interventions that do not work at the expense of those that do.
To achieve the Strategy’s multisectoral response, stakeholders felt there should be greater recognition of the roles played in HIV prevention by domestic and international partners working on education, local government, migration, the prison system, as well as the broader health sector.
A critical component of the new Strategy will be to reduce further the costs and improve the efficiency of HIV treatment programs, especially by utilizing differentiated service delivery.
Stakeholders felt that the strategy needs to prioritize more explicitly those interventions that will deliver maximum impact and are in step with NSPs. In the absence of an effective vaccine, prevention for TB is about effective diagnosis and treatment; some partners did not yet see the case for focusing on presumptive TB treatment (TBT), including for people living with HIV.
The current Narrative fails to recognize that enormous progress has been made in malaria regarding the decline in incidence and mortality, with some highly cost-effective interventions being deployed at scale with Global Fund resources.
Nonetheless, stakeholders felt that there should be greater stress on the diverse impact of malaria which begs the need for more and better tailoring of tools and interventions across and within countries, as a one-size-fits-all approach is no longer optimal.
In the future, stakeholders said, malaria epidemiology will become increasingly complex due to population growth and urbanization, as well as climate change, and interventions need to be more differentiated to meet these varied needs.
Prioritization and Value for Money
Several stakeholders wanted to see a more explicit approach and commitment to the importance of prioritization and VfM throughout the Strategy. This issue had come up as an important issue for several constituencies – including concerns that the disease-focused sections offer up lengthy lists of potential interventions but lack focus.
The roles and responsibilities of each partner
|“There is a glaring imbalance between the discussions of the community roles and the vital role that needs to be played by national governments and what is needed to enhance capacities to play these roles. The COVID-19 experience has shown all too well how important government policies and capacities are for ensuring their citizens are protected and that country systems are sufficiently resilient to cope with shocks. This is not meant to downplay the critical role of community engagement, but the emphasis on community engagement needs to be balanced with highlighting the responsibilities of national governments as well.”|
There has been an ongoing tension between the roles of governments versus other implementing partners, as GFO readers may remember from many of our earlier articles on the Partnership Forums and discussions of the Strategy Framework itself. This has still not been resolved in the Narrative, many commenting that the critical stewardship role of national governments has become almost invisible. Have communities ‘won’, therefore, at the cost of governments?
Some partners were emphatic on the need for the Narrative to include a section on the workings of the Global Fund partnership, the members of the partnership, their roles, and accountability. This section should discuss high-level orientation, including the fact that implementing governments are impossible to replace as a hub for policy development, regulation, domestic funding, service provision, and adoption/change of existing laws.
These stakeholders reiterated that grant implementation should rely on local experts, government and non-state implementers, as stated by the Global Fund founding principle of country-ownership. International NGOs are often Principal Recipients and other private contractors provide costly services paid through the grants which, people felt, negatively impact the Global Fund’s country-ownership principle, are expensive and do not produce better program results. The new Strategy should provide guidance in this area.
Stakeholders recognize the strong connection between equity and the quality and sustainability of Global Fund investments and would like it to be further emphasized upfront, recognizing it as one of the driving forces for creating the Global Fund 20 years ago. It was reiterated that this is a core value of the Global Fund and strongly distinguishes its role among other global health actors. Hence, stakeholders were disappointed to see this section come last.
Moreover, it was deemed to be a pity that this section fails to acknowledge any of the shortfalls made under previous Strategies to maximize the leadership of communities and justify why this objective needs to be elevated under the new Strategy. Again, the call was made for the Narrative to concisely articulate what centering people and communities means ― particularly since the Strategy will be circulated broadly, to people who may interpret and position these concepts differently.
Moreover, the role of communities is currently solely reduced to advocacy, promotion, engagement, and representation. To enhance community and key population (KVP) engagement in Global Fund processes, stakeholders wanted to see dedicated funding streams (that are not dependent on Government approval) for communities and KVPs.
The focus on community-centered and -led approaches needs to be translated into interventions that are fundable within the Global Fund’s mode of operation, make efficient use of resources and deliver a measurable impact in terms of either incidence or mortality. Embedding community-focused principles within a VfM framework would make this clearer, stakeholders felt.
Health equity, gender equality and human rights
While pleased to see the inclusion of the Global Fund’s voice of diplomacy in the work of maximizing health equity, gender equality and human rights, stakeholders were emphatic that for who and what kind of voice is unclear. It was felt that this needed to be expanded and given more weight in the Strategy Narrative; and should include political leverage to reduce restrictive and punishing policies, including the criminalization of KVPs. It was also strongly felt that it is now high time for the Global Fund to limit access to funding of countries that have such punitive and discriminatory laws.
Indeed, some thought that the sub-objective on Gender Equality seems rather siloed. Partners wanted to see the systematic integration of gender-transformative approaches throughout the Strategy: across the contributory objectives and the three diseases, perhaps through a more robust gender analysis which would make it clear how (and how much) gender-related issues are driving incidence and outcomes relative to other factors, and help shape the response. The meaningful engagement of male partners was also not mentioned.
Other areas of the draft Narrative
Health systems and sustainability
Building on the VfM approach, partners felt that the health systems section could benefit from a stronger focus on delivering impact on the three diseases (incidence and mortality) as well as building towards sustainability, in the context of UHC and increasingly stretched domestic resources.
Some expressed a desire to better respond to lessons learned of the past few years (such as the Strategic Review (SR) 2020, PCEs and the various health system strengthening reviews that were undertaken and which identify specific areas where the Fund should evolve its business model to design and implement grants that are more effective for strengthening systems for health.
Actors recommended that the Global Fund focus on high priority areas for investment (data improvement, procurement and supply systems, community system strengthening) and identify ways in which the Fund will do business differently in order to strengthen and build capacity as well as introduce and scale innovation. Moreover, given the increased funding for COVID and PPR, there should be a reference to the opportunity to utilize this for HTM.
Perhaps unsurprisingly given its position as a fourth but cross-cutting objective, there were many views expressed on health financing and resource mobilization. All stakeholders said these are fundamental to the Global Fund’s ability to succeed in implementing this Strategy in an increasingly challenging funding environment. However, people did not feel that this section went far enough.
The domestic resource mobilization section, in particular, needed further elaboration, partners said. The focus not only on quantity but also improved quality of domestic co-financing was appreciated but people wanted to see an explicit emphasis on shifting towards incentivizing and measuring the quality (spend and allocation) of domestic co-financing ― for example, linking to the Africa Union’s tracker indicators. Mention was made of the many different stakeholders who could be called on to catalyze domestic resource mobilization and should be referenced.
The challenges and opportunities of COVID-19 were also mentioned in terms of adding a more general note about innovative financing opportunities.
The 2020 Results Report (see our article 44 million lives saved in total, says the Global Fund Results Report 2021) shows how COVID has had a devastating impact on progress in bringing the three epidemics under control. But some stakeholders felt that this huge challenge could be brought out more in the Narrative since it remains the biggest obstacle to the Strategy’s success. However, on a different note, the lessons learned from COVID-19 forcing us to do things differently in HTM could be better emphasized.
PPR remains controversial. Some stakeholders would like to see a more practically orientated enunciation of the role of the Fund’s investments in PPR and in particular, the opportunity to highlight the dual-use nature of the interventions ― for example, linked to the ‘day job’ or ‘between outbreaks’ for surveillance systems investments. Indeed, it was felt that the flexibility and speed demonstrated by the Global Fund in its response to COVID-19 should inspire a grant-making model better geared towards adaptation, flexibility, and innovation than the current approach and that this requires a stated commitment (noting the success of the Challenging Operating Environment policy as a good example of adaptive management and flexibility).
Sustainability, transitioning and adequate co-financing
While partners acknowledged efforts made to ensure community-led services and CSS sustainability before a country transitions from the Global Fund, they felt that the draft Narrative does not outline adequate measures to ensure that community- and KVP-led services are retained once a country has transitioned, especially in those countries with punitive legal frameworks.
Due to an explicit focus on societal enablers, the draft Strategy consistently mentions sexual and reproductive health and rights (SRHR), gender equality and gender-based violence (GBV). Stakeholders welcomed the emphasis on sexual violence (SBV) and intimate partner violence (IPV) and felt this had the potential to be a ‘game-changer’, as long as it encompassed everyone.