The Global Fund Needs Replenishment – But Not Just Funds. Knowledge, too!
Author:
Madhuri Kamat
Article Type:Article Number: 3
As the Global Fund gears up to meet challenges, we cover the report of Strategic Review 2023 that is an assessment of the work so far. The focus is not on detailing everything but certain of the key issues that emerged of how and where the Global Fund could improve. In this first part of our analysis of the report, we focus on partnerships, guidance and stakeholder feedback from the Board meeting on these subjects.
Strategic Review 2023 Report
The Global Fund’s Evaluation and Learning Office (ELO) commissioned a consortium comprising Cambridge Economic Policy Associates (CEPA) (United Kingdom), BroadImpact (Nigeria) and Southern Hemisphere (South Africa) to undertake the Global Fund’s Strategic Review 2023 (SR2023), which was conducted under the oversight of the Global Fund’s Independent Evaluation Panel (IEP). The SR2023 findings relate solely to the 2017-2022 strategy period, the Global Fund report of which we have already covered in Aidspan. In this article, the first of a two-part series featured in this newsletter, therefore, we choose to focus on the broad areas of partnership, guidance as per our reading of the SR2023 and end with the stakeholder feedback from the Board meeting. Direct quotes from the report are italicized and in other cases, there is an indication of emphasis added or where we are using the quote, it is mentioned as such.
Partnerships – Technical Partners’ Expertise needs to be leveraged more
Who are the Global Fund’s technical partners?
To name a few: UNDP, UNFPA, UN Women, UNICEF and WHO, as well as disease-specific partnerships (UNAIDS, Stop TB Partnership and RBM). Collaboration with CSOs and civil society networks including the International Network of People Who Use Drugs (INPUD), the Global Network of People Living with HIV (GNP+) and Women4GlobalFund.
The Global Fund is able to negotiate the terrain of organizational relationship, capacity and funding with its partners quite well but the problem begins when (a) The Secretariat is seen to be trespassing into the domains of its technical partners and (b) The Global Fund fails to use the full potential of its partnerships to really get going in areas where it is stuck. Let’s examine the first point.
What is the Secretariat doing that it wasn’t doing before that has set off unease? It has taken on the onus of strongly nudging countries in the direction they should take in country prioritization for Global Fund grants. The reason as the SR2023 points out is not hard to find – in a scenario where the Grant Cycle 7 fell short of its expected replenishment, the Secretariat is attempting to select what is perceived to be the appropriate intervention package so as to make full use of limited funds that will show results faster and to offer a pre-emptive, pragmatic way around capacity constraints of countries or partners that could potentially snag impact. But this is not coming from the Secretariat alone. In another part of the SR2023, there is mention of the Observations of the Technical Review Panel 2020-2022 which stated that, “many applicants include too many modules and interventions in a bid to cover all needs outlined in NSPs. This results in a lack of strategic focus, investments not sufficiently prioritised towards highest impact interventions [emphasis by the author] with specific country context to ensure VfM [value for money] and sustainability”.
What is to be read between the lines? What the Global Fund is quoted as saying in another context with regards to the COVID-19 Tools Accelerator (ACT-A), namely, “We must bring this speed, urgency and increased coordination to all of our work.” But not everyone else is up to speed, (pun intended) in the way the Global Fund requires. And among its partners, the World Health Organization(WHO) has taken particular umbrage. More than the other partners have as per the SR2023.
Now watch the Global Fund’s response to the tetchiness: the 2023-28 strategy calls for all partners to ‘accelerate the timeframe between evidence generation, regulatory approval and WHO guidelines’, and for WHO and the Secretariat to work closely to explore ways to expedite the evaluation of innovations through prequalification or the Expert Review Panel. There again, the need for speed.
The SR2023 points out what lies at the roots of this messy interaction: The technical expert is the WHO. However, the Secretariat must wait for it to do what needs to be done (as stated in the above quote) before it can operationalize it. But the tension is also because both the partners, the Global Fund and WHO are on each other’s boards. So, it’s more a question of each also being under pressure of budgetary constraints trying to find common ground but not seeing eye to eye on what this should be. Does the Global Fund fare better with its other partners? It does, with some of them.
Its technical partnerships with PEPFAR and with L’Initiative, France (for bilateral donors’ set-aside) are chugging along smoothly at both the global and country levels, with the former, in fact seeing significant improvement and with the US government overall as well.
An External Evaluation 2022 lauded the above-mentioned Accelerator’s success to the “unprecedented coordination between the largest global health agencies”. These included : Unitaid, FIND, Wellcome Trust, Gates Foundation, Gavi. Following this success, Global Fund and UNITAID were able to agree quickly to their new partnership framework. Again, the speed word!
Which brings us to the second problem the SR2023 points out: In areas of gender equality, where the Global Fund lags significantly, it has not reached out to use the expertise of its partners. The Global Fund has successful collaborations for building capacity and networks at the country level amongst activists for human rights and women’s health, and women-led organizations. CSOs and civil society networks it works with on these include the International Network of People Who Use Drugs (INPUD), the Global Network of People Living with HIV (GNP+) and Women4GlobalFund. But civil society interviewees pointed out that this could be expanded to the global level and also to strengthen gender equality-related programming prioritization at the country level where the WSOs could offer support for such advocacy. There is also potential to expand gender-related programming undertaken by the Global Fund by collaborating with UNFPA’s Safeguard Young People program and the UN-agency-spearheaded Spotlight Initiative. But the Global Fund does not seem to be doing so as per the SR2023, when it could. And its focus remains restricted to adolescent girls and young women in HIV prevention but does not expand to include the sexual and reproductive health rights of women and girls.
The SR2023 also pointed out that it is not possible in the realm of health systems, for instance, for a single entity to offer the entire range of support across various areas such as supply chains, data and human resources. The review recommended that the Global Fund leverage Gavi’s pool for Technical Assistance in the RSSH, that includes not just UN agencies, but civil society, academia and private institutions. Moreover, it also has a funding stream that is both predictable and dedicated to provisioning Technical Assistance that is related to health systems and management.
The new 2023-2028 strategy calls attention of its technical partners to the need to further bolster guidance in norms and prioritization in the areas that require renewed attention such as HIV prevention and malaria. But how does the Global Fund fare when it has to be the guiding light so to speak?
Guidance – It’s just business as usual?
Across different stakeholder groups spanning global and country levels, there was a consensus, which is quite a feat to attain, and that consensus was that the Global Fund business model [emphasis of the author] in terms of the spectrum of policies, processes, and requirements has become overly complicated. And this has led to the guidance becoming unwieldy. An analysis by the Secretariat, (which the SR2023 mentions as confidential) found that the Grant Cycle 6 (GC6) had 48 guideline documents = 1,748 pages! And the GC6 Operational Policy Manual = 400 pages! Civil society and communities are hard- pressed to figure out how to get through the Global Fund requirements and processes. The SR2023 also noted the problem with different terminology: whilst ‘underserved’ is used to refer to priority populations for malaria, this is not universally used, with for example stakeholders in Kenya remarking that use of the term ‘key population’, which is understood more in the HIV context, creates challenges to communicating Human Rights barriers for TB and malaria.
Moreover, while there is acknowledgement that the Global Fund does have an obligation to fulfil its responsibility for financial integrity, sometimes, some countries do feel that the rules it sets out for this can actually derail functional programmes and affect impact. Specific instances are cited, such as smaller civil society organizations unable to apply for funding or key populations remaining out of the program purview when a fiduciary rule being cited led to its scale-back.
To understand why the Global Fund chooses this way of doing things one has only to look at the fact that it is operating out of a business model perspective where the emphasis is on the business-end of things like fiduciary responsibility. So, be it the Office of the Inspector-General, or the interna/external auditors/evaluators, the default mode of recommendation is invariably to «define», «clarify», and the default mode of response by the Global Fund is to «formalize», «refine», «checklist» and so it goes on and on adding more and more to guidelines with no one to rein in the word wizard.
Now, what happens when the WHO, with whom it has a prickly equation issues the «normative guidance» to the Global Fund? Programme Essentials were developed in 2022, based on recommendations by technical partners such as WHO, to ensure standards are maintained in service delivery. But the SR2023 found perceptions were mixed about it, with monitoring of its adherence by countries affected by their capacity constraints. This means that, the Secretariat is not using its influence here when it can and that it’s picky about what it will drive and what it won’t.
The Global Fund as per the SR2023 is going through the African Centers for Disease Control and Prevention (particularly for the malaria control program) rather than the WHO Regional Office for Africa (WHO AFRO), which is perceived by the Global Fund to have capacity constraints. There needs to be a deeper examination of whether this capacity reiteration is more an issue of the need for speed or something else? It is to be noted that the Global Fund’s 2023-2028 Strategy mentions that while there is good progress on HIV mortality reduction, progress is more limited for TB and malaria, both of which have large gaps compared to the ambitious WHO global targets.
In the SR2023, stakeholders at the global level highlighted that countries are initially aligned towards data-driven decision making, but this tends to collapse in the final stages of the funding request in the face of politics and hierarchy among different stakeholders. The same can be said then of the Global Fund and its relationship with the WHO. It is to be noted that, WHO AFRO collaboration worked better as per the SR2023 on the Covid-19 Response Mechanism. So, this partnership needs to be worked on to improve it keeping in mind the Global Fund Mission of eradication of all three diseases. Moreover, it is to be noted that, WHO was the largest institutional recipient of Strategic Initiative funding over 2017-22, indicative of the significance of this partnership, which the Global Fund needs to recognize and respect. As one respondent quoted in the SR2023 put it, “The Global Fund Secretariat now engages with partners when it needs to, rather than [the group of partners] approaching countries with joint responsibility. The Global Fund is increasingly trying to position itself as the key partner for countries, which can cause tensions and question marks.” This is also noticeable in other groupings that the Global Fund is part of with its technical partners. For instance, the Secretariat is now a participant in the SDG-GAP Sustainable Financing for Health Accelerator, which specifically addresses the issue of coordination with other multilateral partners, especially Gavi, World Bank (WB) and WHO. However, the SR2023 points out that the visible benefits were much less with the sole exception of the Sustainable Financing for Health Accelerator (SFHA), where the Global Fund was the co-lead with the WB.
Stakeholder Feedback from the 51st Global Fund Board Meeting
The Global Fund was reminded that it needed to ensure that its approach to sustainability is consistent with other global health institutions. The Board must also articulate priorities clearly. The business model being currently followed has to be simplified. Emphasis was laid on engaging external stakeholders in creating operational guidance to ensure that procurement practices are inclusive and comprehensive. Implementation of the recommendations from stakeholders mentioned in the report could strengthen the Global Fund’s effectiveness in achieving its strategic objectives for ensuring global health outcomes. Collaborations across the board to align Global Fund activities with global health challenge imperatives will be key in this implementation.
Conclusion
The SR2023 speaks of how structures outside the Board governance structure are working really well and these involve the Global Fund’s partners in disease coordination platforms for HIV, TB and malaria at the global level as an informal consultative forum for independent advice and mobilisation to address bottlenecks in delivery of Global Fund financed country programs. These include the TB Situation Room; the Roll Back Malaria-hosted Country/Regional Support Partner Committee (CRSPC); and HIV situation room in partnership with PEPFAR.
This informality also worked well for the Board itself. The Board’s Governance Assessment report has mentioned – “During Covid, what really worked is that the Secretariat had very regular updates: information sharing and not necessarily a decision to be taken. They communicated a lot and people felt heard and could interact much more than Board meetings and Committee meetings.”[emphasis by the author].
The SR2023 also lauds the catalytic funding design by the Global Fund in partnership with Stop TB as also their collaboration on finding missing TB cases. The reasons cited was the coordination between the two but also that the Catalytic Investment was: thoughtfully designed…which combined the Matching Fund that provided extra money for countries to implement (thus supporting country ownership) with technical assistance at global and country levels, and also the sharing of best practices and lessons.
It is this combination that needs to be replicated in the Global Fund structures – Listen, Learn, Leverage.
