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GFO Issue 389



Djesika Amendah

Article Type:

Article Number: 5

However, progress toward building health systems and promoting human rights is more subdued

ABSTRACT The Global Fund’s midterm review indicated that the organization is on track to maximize disease impact but not to strengthen health systems or promote human rights and gender equality. The report offered recommendations for the second half of this strategy as well as the following one.

The Technical Evaluation Reference Group (TERG) of the Global Fund to fight AIDS, Tuberculosis (TB), and Malaria commissioned a mid-term review of its 2017-2022 strategy. The review found mixed progress towards the strategic objectives (SOs).

The Global Fund has made good progress towards its first SO to “maximize disease impact.” However, progress towards strengthening health systems as well as promoting human rights and gender equality, the second and third objectives, was limited. The review noted that the business model is strong and relevant, but it fails to simultaneously pursue all objectives and coordinate actions with partners. Additionally, the business model does not create strong and clear incentives for partners and other stakeholders to improve program results.

The review was conducted between December 2019 and August 2020. It aimed to assess the outcomes and impact of the Global Fund against its objectives and implementation of the current strategy. Based on lessons learned from the first half of this strategy, the review offered recommendations to better position the Global Fund among other health development organizations for the next strategic cycle. Information for this article comes from the report and its annexures.


The review was conducted by the Euro Health Group (EHG), Itad, and the University of California, San Francisco (UCSF). The reviewers used a mixed-method analysis. They analyzed existing secondary data, conducted interviews and focus group discussions with the Secretariat, partners, and global health leaders, including the Global Fund Board members. They also conducted structured case studies of 11 countries.

The authors acknowledge some limitations due to the COVID-19 pandemic, which restricted travel and access to people. Another limitation is the scarcity of data on the first half of the strategy as results of some investments take time to materialize due to time lags.

Assessment of the outcomes and impact of the objectives

Good progress towards maximizing disease impact but limited progress for health systems, human rights and gender equality

The Global Fund made much faster progress in fighting HIV than malaria and TB. HIV-related deaths declined by 17% between 2015 and 2019, while malaria-related deaths declined by 9.2% between 2015 and 2018, and TB-related deaths by only 2.9% between 2015 and 2018. The Global Fund will probably miss the target of reducing new infections by 38% for each of the three diseases. Further progress will depend on the improvement of the quality of care. Indicators for treatment retention for HIV or TB treatment success (the proportion of patients who complete treatment) are weak.

For health system strengthening, the Global Fund has invested predominantly in two areas with some success: data systems as well as global and in-country procurement and supply-chain management (PSM) systems. But even in those areas, substantial challenges remain which restrict the impact of Global Fund investments in health.

For the human rights and gender equality objective, the review stated that issues that cause inequity “do not receive sufficient attention” in funding requests and grants. Achievement of this objective is often restricted by the lack of political will to address structural barriers that hamper key and vulnerable populations’ access to care.

The review listed several structural barriers and issues that hamper grant implementation. They include:

  • existing cultural norms, including stigma and discrimination
  • a lack of sufficient interaction between the government and civil society organizations (CSOs)
  • an inherent conflict of interest when CSOs act as an advocate for key populations and watchdog as well as a service provider
  • legal frameworks
  • a lack of a clear indication of the value added by CSOs by their corresponding governments
  • a conflation of international non-governmental organizations (perceived as expensive) versus local non-governmental organizations.

The funding model

The review found that the funding model works well, however the funding requests do not integrate SOs simultaneously. The review cited a lack of overall frameworks or strategies for monitoring, evaluation, and learning (MEL). This led to a “lack of processes to promote a learning culture that draws on monitoring data and wider evidence on what works and why.” The former Inspector General drew a similar conclusion in an interview with Aidspan. The review highlighted gaps in the coverage of the MEL system: technology utilization, health systems, human rights and gender equality, partnership, and technical assistance. The review mentioned that the grant indicators measure national objectives based on the national strategic plans. Attaining some of those indicators is beyond the scope of the grants depriving implementers and partners of an incentive to improve grant performance. Choosing key performance indicators that can actually be achieved by the grants is necessary, according to the report.

According to the review, the Secretariat moved towards a better balance of fiduciary and programmatic risk management. (The Global Fund used to emphasize fiduciary performance which often came at the expense of the programmatic performance especially in challenging operating environments, according to the OIG). Going forward, the Secretariat should also focus on changing the organizational culture and external stakeholders’ perceptions of that culture.

Market shaping and efficiency in implementation

In terms of procurement and market shaping, the Global Fund has delivered significant value in the space directly under its control. The Global Fund has greatly improved the availability and affordability of heath technology, with market-shaping successes across product categories and contributions to broader health product management. This improvement is linked to the scale-up of biomedical and facility-based services, including testing and treatment.

The review noted that grant efficiency increased over time. However, efforts to improve efficiency often occurred with the scale-up of the biomedical aspects of the grants, which is SO1, while interventions related to health systems and human rights and gender objectives (SO2 and SO3) fail to absorb funds initially allocated to them. The review praised the Global Fund’s efforts towards greater sustainability through the application of the sustainability, transition, and co-financing policies, but noted that the COVID-19 pandemic threatens these gains in the future.

Strategic recommendations

The report ended with five strategic recommendations.

The first one was to strengthen the national strategic plans’ prioritization processes, on which the funding requests are based. Thus, it would be possible to reach an adequate balance between attaining SOs and value for money. The second was to prioritize achieving results during the remainder of this strategic period.

The review recommended that the next strategy includes strengthening the Global Fund’s ability to adapt to the range of possible contexts that it might operate in post-COVID-19. The review also recommended that the current SOs 1, 2, and 3 be retained in the next strategy and emphasized that those SOs are mutually dependent, thus pursuing one should not be at the expense of others.

The final recommendation is to make programmatic and financial sustainability for the three diseases response a high-level strategic priority and ensure mechanisms are in place to operationalize this priority.


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