Review of Global Fund Window 1 funding requests reveals resurgence of malaria in Central and Eastern Africa, TRP says

1. NEWS
15 May 2017
Other lessons learned from Window 1 are identified

The Technical Review Panel (TRP) says that based on its review of the funding requests in Window 1 of the current funding cycle, it believes there has been a resurgence of malaria in Central and Eastern Africa and that a change in approach is required.

The TRP said that it had observed poor outcomes in malaria in these regions and that it was concerned that the countries involved had not yet understood the reason for the significant change in the epi situation. The TRP said that an “urgent operational investigation” is needed to understand the root causes of the lack of success in region, and to propose a new way forward. “A concerted effort may be needed, in addition to a national response.” The TRP noted that several countries reported that the usage of bed nets is declining. It said that it had observed this even in low transmission settings.

This information is contained in a TRP debriefing document which Aidspan has obtained from the Secretariat. The document describes the outcomes of the TRP’s review of the Window 1 funding requests as well the lessons learned from these requests. The TRP is planning to produce a report for public release but not until after it has also reviewed the requests from Window 2, for which the deadline for applications is 23 May 2017. 

The TRP has prepared similar reports in the past for each round of funding under the rounds-based system and for the first cycle of funding under the new funding model. This is one of three articles Aidspan has prepared based on the TRP debriefing document. In this article, we report on (a) the outcomes of the TRP’s review of Window 1 funding requests (including requests for Matching Funds); and on (b) the general lessons learned from the review. In a second article in this issue, we provide information on the technical lessons learned for malaria, TB and HIV. And in a third article in this issue, we report on the lessons learned in two priority areas: sustainable systems for health (RSSH), and gender and human rights.

Outcomes of Window 1

The Secretariat should expect a significant increase in reprogramming requests because the program continuation approach did not allow for any material changes to the program; the Secretariat should plan accordingly.

In Window 1, 91 funding requests were reviewed, of which 39 were for malaria, 21 for HIV, 14 for TB, and 14 for TB/HIV jointly. In addition, two funding requests were fully integrated (i.e. the requests included TB, HIV, malaria and cross-cutting RSSH components) and one was for stand-alone RSSH.

In terms of the type of funding requests, the 91 applications break down as follows: 72 were program continuation, 12 were full review and seven were tailored review.

Of the 91 applications, 95% were recommended for grant-making, which means that only 5% were sent back for iteration. Of the 19 full review and tailored applications, 11% were returned for iteration. This compares to a 23% iteration rate for funding requests in the 2014-2016 funding cycle.

The applications recommended for grant-making represent $4.6 billion in allocation funding, which is 45% of the $10.3 billion allocated for 2017-2019. The applications also included $921 million in prioritized above-allocation requests (PAARs).

The country teams in the Secretariat estimate that another 58 requests will be submitted in Window 2 (deadline: 23 May 2017), and 19 in Window 3 (deadline: 28 August 2017).

Of the 17 TRP members who participated in a survey on the quality of Window 1 applications, 94% agreed or strongly agreed with the statement that the majority of funding requests were considered good or very good quality. The survey also showed that:

  • 71% agreed or strongly agreed that the requests demonstrated a strategic focus on RSSH;
  • 53% agreed or strongly agreed that the requests addressed gender-related barriers to services; and
  • only 29% agreed or strongly agreed that the requests addressed human rights barriers to services.
 

General lessons learned

In its debriefing document, the TRP commented on overall program quality; the use of differentiated applications; and whether sustainability was adequately addressed. Program quality

The TRP said that overall, the quality of the funding requests was good. It said they were shorter and more focused than the requests from the 2014-2016 cycle, and that there was better awareness of key populations across all three diseases. The TRP said that improvements were still needed in the following areas:

  • disaggregation of data on age and gender, and at the sub-national level;
  • analysis of the HIV treatment cascade, and using this analysis to improve program design;
  • deeper analysis of the reasons behind poor outcomes (the TRP said applicants should avoid defaulting to “business as usual”); and
  • sustainability planning (see below).
 

The TRP also said that countries should think more about the populations who are at greater risk and who have less access to services – beyond what the TRP called the “traditional” key populations.

The TRP said that it is difficult to assess if cross-cutting health systems investments are sufficiently strong when a disease component application is submitted prior to an RSSH application. A spokesperson for the Secretariat told Aidspan that the TRP is essentially saying that it is difficult, if not impossible, to understand the health system context and planned investment when it does not have a complete picture. The TRP would prefer that all components were submitted at the same time.

The spokesperson said that for the 2017-2019 funding cycle, the Global Fund has requested that, when possible, countries include their cross-cutting RSSH investments in one application (either with a disease request or in a stand-alone RSSH funding application), ensuring that it covers the needs of all eligible diseases. Ideally, the spokesperson said, the request for RSSH initiatives would be submitted with the first funding request submitted by the applicant. 

Differentiated applications

The TRP said that program continuation was “broadly successful as an application approach” and that the amount of information was usually sufficient to make decisions. But the TRP added that it missed having modular-level budgets, especially when the allocation for the component had been significantly reduced.

The TRP recommended that in future the program continuation approach not be used for applicants whose allocations were significantly reduced (unless government takeover of activities is well underway). The TRP explained that when there has been a significant reduction in the allocation, reprogramming and new budgeting will be required and the TRP will need to see what will be cut. In these situations, the TRP said, applications should use the tailored-to-material-change approach instead.

Sustainability is still not being sufficiently addressed in the funding requests… “Sustainability should encompass programmatic, systems, equity and financing considerations.”

The TRP said that program continuation was most appropriate for those countries that have just started to implement a program; but that, compared to the full review approach, program continuation did not lend itself to innovative thinking. (For an example of what the TRP was talking about, see Gemma Oberth’s GFO article on Zanzibar’s TB/HIV funding request.)

The TRP said that the Secretariat should expect a significant increase in reprogramming requests because the program continuation approach did not allow for any material changes to the program; and that the Secretariat should plan accordingly. The TRP recommended that reprogramming be a simple process “so as not to distract from implementation.”

The TRP said that the tailored reviews seemed to go well, but it acknowledged that the Window 1 sample size (seven) was small. In its debriefing document, the TRP did not say anything about the full reviews, of which there were 12. However, the full reviews closely resembled the reviews carried out on all funding requests in the last cycle, so the approach was not new.

Sustainability

The TRP said that sustainability is still not being sufficiently addressed in the funding requests. The goal is for impact to be sustainable, the TRP said. “Sustainability should encompass programmatic, systems, equity and financing considerations,” it added. “Applicants [are] not yet considering sustainability in all program approaches.”

The TRP believes that the programs at biggest risk of not being sustainable are the large-scale ones such as the treatment of multiple-drug-resistant TB, the provision of antiretrovirals and mass distribution of bed nets. One strategy to promote sustainability is to link disease control to Universal Health Coverage and national governance and economic development strategies, the TRP said.

Better guidance is needed on all dimensions of sustainability, the TRP concluded.

Matching Funds

In addition to reviewing 91 funding requests, the TRP also assessed 14 requests for Matching Funds from seven countries. Matching Funds are designed to inspire innovation and ambitious programming approaches driven by evidence, in order to maximize impact in specific strategic priority areas.

The TRP recommended that 11 of the requests for Matching Funds proceed to review by the Grant Approvals Committee (GAC). The 11 requests totaled $66 million, which is 18% of the $356 million Matching Funds budget for 2017-2019.

See the table below for a list of the 14 requests for Matching Funds. In its debriefing document, the TRP did not indicate which 11 of these requests were recommended to proceed to the GAC for further review.

Table: Requests received in Window 1 for Matching Funds, by priority area

Priority area
Country
Funding ceiling ($ million)
HIV (key populations impact)
Zimbabwe
9,9 m
HIV (removing human rights gender barriers)
Philippines
1,0 m
Sierra Leone
1,8 m
Uganda
4.4 m
HIV (adolescent girls and young women)
Malawi
7,0 m
Uganda
5,0 m
Zimbabwe
8,0 m
TB (finding missing cases)
Bangladesh
12,0 m
RDC
10,0 m
Philippines
10,0 m
RSSH (integrated services delivery)
Sierra Leone
2,9 m
RSSH (data systems)
Bangladesh
1,0 m
Malawi
3,0 m
Sierra Leone
2.0 m
 

The funding ceilings and the list of eligible countries were established by the Secretariat. In its debriefing document, the TRP did not say whether the countries had applied for the full amounts.

The TRP said that Matching Funds are a significant opportunity for applicants because of their catalytic effect and their potential for innovation. Where it sent applications back for iteration, the TRP said, it was because the request was not evidence-based or because the applicant did not adequately make the case that what was being proposed was innovative; and/or because the applicant’s portion of the Matching Funds were not identified in the application or were placed in the PAAR instead of in the base allocation request.

The TRP recommended that applicants submit requests for Matching Funds as soon as possible in this funding cycle to maximize potential impact. The TRP also recommended that applicants identify larger investments in fewer activities as opposed to smaller investments in a larger number of activities, to enable better quality evaluation and to maximize the potential for impact.

The TRP further recommended that applicants cite existing evidence to justify the activities being proposed or, where that is not possible, that applicants propose a pilot designed to be scaled up based on findings.

Finally, the TRP recommended that applicants plan for a simple evaluation of the activities implemented with Matching Funds.

The TRP’s debriefing document on Window 1 funding requests is on file with the author. The TRP is scheduled to review Window 2 funding requests from 19-28 June 2017.


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