14 Jan 2019
TRP releases report on RSSH investments from 2017 to 2019

Despite the progress that has been made, a greater focus on resilient and sustainable systems for health (RSSH) will be required in the 2020–2022 allocation period if the Global Fund is to achieve its RSSH-related strategic objectives, the Technical Review Panel (TRP) says in a report released recently on RSSH investments in the 2017–2019 allocation period.

The 54-page report provides a comprehensive analysis of RSSH-related gaps in funding requests and advances numerous recommendations on how applicants, the Global Fund and partners can address these gaps.

The TRP analyzed RSSH investments in funding requests submitted in the first five windows of the 2017–2019 allocation period. (There were six windows in all.) Fifty funding requests were selected for in-depth analysis. These requests constituted 25% of the number (and 38% of the value) of the requests reviewed by the TRP in the first five windows.

The TRP said that attention to RSSH increased significantly in the 2017–2019 allocation period. Not only were RSSH investments reflected in stand-alone RSSH applications, but they also constituted a considerable portion of the disease funding requests. On average, the TRP said, 13% of the budgets in the funding requests it analyzed was invested in RSSH. The matching funds and ‘above allocation’ requests also contained RSSH investments.

The TRP observed a number of ‘positive investments” in RSSH, including substantial investments into health information systems and progress towards electronic and interoperable data systems; and health systems investments to support innovative service delivery models, including at the community level, to extend services to key populations.

However, the TRP said, considerable challenges remain. The report identified seven high-level issues that need to be addressed. They are:

Issue 1: Focused attention to RSSH has been observed in funding requests. Further strategic and prioritized RSSH investments should be encouraged across health systems components. However, significant challenges remain.

Issue 2: Further differentiation of RSSH investments is needed along the health systems development continuum [see below], with a greater shift from systems establishment and support, to systems strengthening and sustainability.

Issue 3: Weak RSSH indicators, including low uptake of indicators, negatively impact performance monitoring and accountability.

Issue 4: Significant efforts are needed to achieve stronger integration across the three diseases and with other health programs, such as RMNCAH [reproductive, maternal, newborn, child and adolescent health] and non-communicable diseases, where integration can strengthen service delivery, improve efficiency, equity and/or impact and value-for-money.

Issue 5: Comprehensive broad engagement beyond the health ministry is needed to strengthen vital elements of the health system.

Issue 6: Sustainability: Limited attention in funding requests to strengthening health systems components vital to sustaining disease impacts.

Issue 7: There are opportunities to further improve the application approach and process to better respond to RSSH needs.

The report described the health systems development continuum as a “4S model” –– Start-up, Support, Strengthening and Sustainability (see Table 1 below).

Table 1: General evolution of health systems development: the 4S model

Parameter System
System support System
Scope Emergency; early development of systems May be focused on a single disease or intervention Activities have impact across health services and outcomes

Systems are integrated, resourced and fully incorporated into the overall health sector

Longevity Short term; depending on country situation Effects limited to period of funding Effects will continue after activities end

Effects are continuing without external/extra support

Approach Input heavy for all systems Provide inputs to address identified system gaps impacting service delivery Revise policies and institutional relationships to change behaviors and resource use to address identified constraints in a more sustainable manner

Systems are adjusted to adapt to changes and resources are continuous, relevant and available domestically

In the part of the TRP report where the high-level issues are identified (Section 3.1), the issues are described and some recommendations are advanced. In the next part of the report (Section 3.2), most of the same issues are discussed in more detail, but organized differently. Section 3.2 contains nine sub-sections, as follows:

  1. Health management information systems
  2. Procurement and supply management
  3. Human resources for health
  4. Integrated service delivery
  5. Community systems and responses
  6. Private sector engagement
  7. Governance, leadership and accountability
  8. Health sector financing and financial management
  9. Program implementation and management.

For this article, we have chosen to follow the format of Section 3.2. For each sub-section, we describe the issues and we summarize the recommendations advanced by the TRP. For space reasons, we will publish separate articles for Sub-Sections 3 (human resources for health) and 4 (integrated service delivery) in a future edition of the GFO.

Health management information systems (HMIS)

The TRP said that some countries continue to use multiple data management systems with unclear complementarity. In addition, it said, HMIS is often not connected to other relevant management systems, such as laboratory or logistics information systems.

Although large HMIS investments have improved the availability of data, the TRP observed, “use of this data and its influence on program management is often not evident in funding requests.”

Many funding requests missed opportunities to analyze, interpret and use available programmatic data to improve the selection of interventions, the TRP stated. “In the case of malaria, opportunities remain for applicants to make better use of existing data on age, sex, population mobility and demographics to facilitate identification of the most vulnerable populations; understand whether they access services; and design appropriate interventions, including selection of vector control interventions.”

For HIV, the TRP said that it was still seeing gaps in the availability of certain data, such as the size estimates of key populations; gender and age data breakdown; and data on policy or legal barriers to accessing services for key populations.

In TB, since health management information systems often do not disaggregate treatment outcomes by sex, gender or age, the TRP observed, funding requests do not present sex- and age-differentiated treatment outcomes and identify factors that might be associated with inequities.

TRP recommendations: Health Management Information Systems

  • Countries should avoid introducing parallel data systems.
  • Available program data should be used to make better resource allocation decisions.
  • Applicants should include activities in the funding request that promote the use of, or improve the quality of data.
  • The Secretariat should consider updating guidance to shift the focus from establishing integrated information systems to investing to ensure that data is used for program management and monitoring.


Procurement and supply management (PSM)

The TRP noted that a large number of funding requests continue to acknowledge serious PSM challenges. Stock-outs, above-market prices and sub-standard product quality continue in many settings, the TRP said; funding requests documented weaknesses in forecasting, logistics management information systems, quality assurance and control, and coordination among partners. 

These challenges are underpinned by human capacity limitations, weak PSM-related financial, operational and administrative systems and –– ultimately –– weak use of performance indicators to monitor PSM performance, the TRP stated. This issue is linked to several other challenges –– specifically the lack of information in funding requests on PSM support from national governments and other donors; inadequate use of performance indicators; and lack of consistent language and definitions used for PSM.

Although countries often focus on interventions to address warehousing and logistics constraints at central, regional and sometimes district levels, the TRP said, delivery of supplies below the district level (the last mile) is infrequently addressed.

Many applicants directed their co-financing commitments to the purchase of commodities, the TRP noted, but the systems were not always in place to support the transition from programs supported by the Global Fund to government programs.

While the Global Fund provides substantial funding for new technologies such as GeneXpert and HIV self-testing, the TRP observed, funding requests do not consistently provide information on the complementary health systems that need to be in place for new technologies to achieve their intended impact. For example, many applicants request funding for new viral load machines without explaining how the challenges of using both existing and new machines will be addressed.

TRP recommendations: Procurement and supply management

  • Applicants should ensure that requests for PSM funding are informed by a clear gap analysis and that they identify expected improvements, with targets against which progress will be tracked.
  • Applicants should ensure that their funding requests explain how the CCM will work with partners to implement a strategy to address last-mile delivery challenges.
  • Monitoring should include measures to track improvements at lower-level health facilities.
  • Applicants should work with the Secretariat to mitigate the risks of transitioning drugs to domestic financing. Applicants’ analyses of transition readiness and risk mitigation strategies should be made available to the TRP to inform its assessment of whether the proposed transition is technically sound and sustainable.
  • Applicants requesting funding for new technologies should include an analysis of the readiness of the health systems to support the introduction of the technologies.


Community systems and responses

“Only a small number of funding requests propose activities for strengthening community systems that are comprehensive and at sufficient scale to make a difference,” the TRP observed. “Overall, few applications request support to increase the engagement of communities to address gaps in coverage across the three diseases. Even fewer include funding to support communities to advocate against unsound and inequitable policies, laws, and regulations. Where they exist, such efforts are often limited in scope and scale.”

Where support is requested for community systems strengthening, the TRP said, proposed activities tend to focus on extending service delivery at the community level. “Such programming is often limited to deploying CHWs [community health workers] with narrowly defined responsibilities and insecure contractual arrangements,” the TRP stated “and does not focus on strengthening broader community responses. Only a few applicants have requested support to strengthen community health systems in ways that ensure integration within the overall health system.”

Too few programs are built for sustainability, the TRP said; many programs do not subsume CHWs with disease-specific responsibilities into human resources for health plans. And few funding requests discuss gender considerations in recruitment and deployment of CHWs.

The TRP noted that among countries approaching transition from Global Fund support, few developed robust mechanisms to ensure sustainable funding for community systems responses.

Finally, the TRP commented that evaluations of progress in community systems and response efforts rely too heavily on activity-level indicators. “Too little attention is paid to assessing the degree to which community systems responses are contributing to lifting human rights and gender-related barriers to access, and improving coverage and quality of care.”

TRP recommendations: Community systems and responses

  • Applicants should include initiatives in funding requests to increase the involvement of civil society organizations (CSOs) in governance, planning, service delivery and accountability monitoring mechanisms.
  • The Global Fund, partners and applicants should promote and facilitate capacity building for CBOs and NGOs. Organizations serving key populations deserve special attention.
  • Applicants should ensure stronger linkages between emerging community health systems and the formal health system.
  • Applicants should enhance collaboration between disease programs and with other primary health care programs.
  • Applications should introduce mechanisms to provide official recognition and more reliable compensation packages for community workers.
  • Countries nearing transition should be asked to provide country sustainability plans as part of their funding requests and to demonstrate that CSOs were meaningfully engaged in the development of these plans.
  • Countries should develop social contracting mechanisms or other innovative financing approaches to support the work of CBOs and NGOs, especially with respect to providing services to key populations.
  • Where necessary, community organizations should be provided with technical assistance to strengthen their capacity to interact with governments at different levels.
  • The Secretariat should work with partners to identify appropriate indicators to track community systems responses. The indicators should track both the level of engagement of communities in the activities supported by the Global Fund and the results of the investments.


Private sector engagement and public-private mix

There is limited inclusion of private sector health services in national plans and funding requests, the TRP remarked.

In recent review windows, the TRP said, there has been greater acknowledgement of the importance of public-private mix (PPM) in service delivery. “However, how PPM would be leveraged and funded are not clarified,” the TRP said. “When PPM is included in the request, the assigned budget or the scope and ambition of the work proposed are inadequate.”

Where PPM initiatives have been included, the TRP said, there is usually insufficient information in funding requests to enable the TRP to determine whether the PPM strategies proposed are appropriate. For example, how the private sector will reach key populations such as migrants, refugees and minority groups in remote areas is often not explained.

Although the quality of care provided by private sector facilities is an issue of concern in many countries, the TRP observed, funding requests do not address mechanisms to monitor the quality of service provision, the quality of inputs (such as drugs) to private sector providers, and the quality of outcomes.

TRP recommendations: Private Sector and public-private mix

  • The Secretariat should develop guidance on PPM for applicants which situates PPM investments in the context of the 4S development continuum.
  • Countries that are new to PPM should include in the funding request pilots and research on costs, access and impact of PPM approaches. Countries with existing PPM approaches should provide evidence in the funding request of the pilots’ cost and impact.
  • Applicants should undertake strategic planning, including mapping the interventions funded by other donors; identifying and analysing the gaps; clarifying the roles, coordination and collaboration between the non-state actors and government institutions; establishing a social contracting mechanism through which NGOs will be funded; and specifying the capacity-building and other communities systems strengthening needs of the civil society and how exactly and by whom they will be addressed.
  • Partners should support countries to strengthen regulatory approaches; to disseminate lessons learned; to better understand private sector delivery models; and to promote cross-learning.


Governance, leadership and accountability

“There has been limited investment by the Global Fund into building leadership, strengthening governance, or supporting institutionalization of health systems in countries (with a few notable exceptions, mainly in transition countries),” the TRP observed.

The TRP said that funding requests seldom propose interventions to strengthen participation in governance systems by groups that are under-represented in decision-making, including women and representatives of civil society.

The TRP noted many cases, including in transition countries, where leadership around the contracting of services to NGOs was not sufficiently robust. “The re-entry of several countries into Global Fund financing after their transition, as well as increasing rates of HIV transmission in some countries approaching transition, gives cause for concern,” the TRP said.

TRP recommendations: Governance, leadership and accountability

  • The Global Fund and applicants should identify metrics for measuring and tracking stewardship.
  • Applicants should link Global Fund investments in the three diseases to broader stewardship of the health sector. Applicants should be encouraged to identify the role of parliament, the extent of negotiations with the ministry of finance, the budget cycle, and accountability processes in their funding requests.


Health sector financing and financial management

Very few funding requests included initiatives to develop national health financing strategies, the TRP remarked. The TRP said that there is insufficient information in most funding requests to enable a sound assessment of the funding landscape and the sustainability of proposals. In addition, the TRP said, there is insufficient emphasis in funding requests on implementation arrangements for the effective flow of funds and financial management.

Based on evidence annexed to funding requests and references to previous grants in most requests, the TRP said, domestic budget expenditure rates are often significantly under 100%. “From a health systems strengthening perspective, spending all available public funds in accordance with planned budgets is vital to building systems, and in itself requires strong, well-managed financial systems,” the TRP commented. Few funding requests include support for financial management or public expenditure capacity building, particularly at a decentralized level, it said.

TRP recommendations: Funding Requests

  • Funding requests should include a table of basic macroeconomic and financial data.
  • The Global Fund should promote sustainable financing systems in all countries eligible for funding by investing in health systems financing.
  • Applicants should put greater effort into guilding and tracking progress in health financing and financial management systems.


Program implementation and management

The TRP said that it commonly saw funding requests with program management costs of 25–30% and that a few smaller grants had management costs of 50% or more.

Where separate program implementation arrangements are put in place, the TRP said, they create barriers to sustainability because they build financial management, decision-making capacity and accountability among external entities rather than within the public sector.

“Furthermore,” the TRP said, “in countries that rely on contracting, a lack of investment into government or public sector capacity and commitment to contract services (for example, for NGOs to provide services to key populations) puts those services at risk following transition.”

The TRP said that it saw funding requests from countries approaching transition that continued to rely on external implementation support funded by the Global Fund.

TRP recommendations: Programme Implementation and Management

  • Implementation approaches should reinforce national systems strengthening.
  • The Global Fund should develop a best practice guide on project implementation approaches using a health systems strengthening lens.
  • Where parallel implementation arrangements are deemed to be essential for successful service delivery, the Global Fund should require applicants to describe the capacity-building activities and support they will undertake as part of grant implementation with a projected timeline and milestones to build a financial management function within national entities.

Editor's note: This overview of the TRP's RSSH report is one of three GFO articles on the subject; the other two, on integrated service delivery and human resources for health, will be published in a future edition of the GFO.


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