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Lessons learned can still provide valuable insights for future applications
On 17 July the Technical Review Panel (TRP) debriefed technical partners, including technical assistance providers and others, on its findings from the funding requests (FRs) submitted under Window 2 (W2).
This article is based on the presentation and because of its length is in two parts: Part I covers the thematic findings and recommendations; and Part II covers the technical observations and recommendations by disease and resilient and sustainable systems for health (RSSH) and will be published in GFO 436 on 30 August.
Funding requests in 2023
Over 200 FRs are expected to be reviewed in the 2023-2025 allocation period. Over half of these have now been reviewed by the TRP in the first half of 2023.
Figure 1. Funding requests in the 2023-2025 application cycle
Source: The Global Fund, 20 June 2023
Window 2 TRP review outcomes
61 out of 63 W2 FRs have been fully recommended for grant-making. One FR was iterated, and one component of an integrated FR was iterated, resulting in a “partial” recommendation.
Figure 2. Overall TRP review outcome, Window 2
Source: The Global Fund, 17 July 2023
TRP has recommended $4.9 billion in funding for grant-making in W2, including both allocation funds and matching funds. Together with W2, more than two-thirds of the allocation has now been reviewed and recommended.
Table 1. Recommended amount in funding for grant-making, as of 17 July 2023
Source: The Global Fund, 17 July 2023
TRP has recommended all Matching Funds reviewed in W2, noting that several countries will need to continue to work towards fully meeting all conditions during grant-making.
Table 2. Matching fund priority areas recommended for grant-making
Source: The Global Fund, 17 July 2023
TRP Funding Request Quality Survey
Overall, according to the TRP Funding Request Quality Survey on Window 2 FRs Recommended for Grant-making, 72% of TRP members agreed that the W2 FRs delivered strategically focused and technically sound responses aligned with the epidemiological context and maximizing the potential for impact. 26% of TRP members even went as far as to say they “strongly agreed” that this was the case. Only 2% disagreed; which was less than under W1 (5%).
Figure 3. TRP members who felt that funding requests were focused and technically sound, %
TRP Funding Request Quality Survey: RSSH
TRP observed a “strategic focus” on RSSH in 85% of Window 2 FRs recommended for grant-making. This is eight points higher than in W1 and 14 points higher than GC6 (NFM3) overall, although FRs’ focus is still more on system support than on system strengthening.
Among FRs which include investments in Pandemic Preparedness, the TRP saw that appropriate investments were being made (77% positive) and that these investments mostly complemented the COVID-19 Response Mechanism (C19RM) funds (83%).
Figure 4. Window 2 funding requests’ focus on RSSH
Source: The Global Fund, 17 July 2023
TRP Funding Request Quality Survey: Sustainability
TRP observed substantive improvements in how FRs addressed Sustainability in W2 (87% positive compared to 79% in W1), Value for Money (89% positive in W2, 77% in W1), and Co-financing (73% in W2, 64% in W1). This is a significant shift from GC6, when the question which integrated sustainability and co-financing was 67% positive. The score on Community Systems and Responses is lower than in W1 but still broadly positive (75% in W2, 87% in W1).
Figure 5. Sustainability, Value for Money, Co-financing and Community Systems & Responses under W2
Source: The Global Fund, 17 July 2023
TRP FR Quality Survey: Equity, Gender and Human Rights
TRP saw strong positive movement on equity in W2 funding requests (87% positive in W2, 77% in W1). Scores on gender (69% in W2, 69% in W1, 58% in GC6) and human rights (67% in W2, 64% in W1, 66% in GC6) were relatively consistent compared to W1, but gender has made progress since GC6.
Figure 6. Equity, Gender and Human Rights in Window 2 applications
Thematic observations and recommendations
Thematic Lesson 1: Countries are either over- or under-ambitious when it comes to delivering programs
The TRP noted that several FRs demonstrated a lack of ambition. Conversely, there were also examples of too much ambition.
|Examples of “too little” ambition||Examples of “too much” ambition|
|HIV: Limiting pre-exposure prophylaxis (PrEP) scale-up plans to specific groups or urban areas. Limited introduction of innovative tools such as Dapivirine-Ring and CAB-LA. Poor HIV cascade for children||Focus on innovation and ambition but basics (managing advanced HIV, retaining people on treatment) aren’t in place. Highest-impact interventions not given sufficient attention compared to “new” interventions|
|TB: Unambitious targets on treatment coverage, DR-TB detection, child TB case finding, TPT, decentralized services for child TB and drug resistant (DR)-TB||Ambitious lab strategies but inadequate investments in lab infrastructure, equipment and human resource capacity|
|Examples where applicants planned lots of activities to increase case findings yet didn’t increase targets||Targets not matching reality, e.g., HIV with poor cascade but ambitious testing targets, malaria with low antenatal care (ANC) coverage but ambitious IPTp-3 targets|
|Covering-over gap of ineffective health system by increasing investments in community health workers (CHWs) but not in communities providing services||Countries proposing scaling up injectable PrEP with no well-organized HIV prevention programs or oral PrEP delivery models to build on, and/or weak existing antiretroviral treatment (ART) programs|
|Mismatch between ambition to adopt new tools and country’s readiness to use them (e.g., proposal includes deployment of digital innovations)|
|X-rays with CAD in mobile vans, but no internet for Al, no radiologists to interpret the films|
|Applicants “peppering” FRs with Global Fund Strategy language (particularly in relation to gender, human rights and community) but with a big gap in programs, budgets and ability to achieve it|
The TRP made several suggestions for improvement aimed at applicant countries and partners submitting FRs under the next two Windows:
- Don’t forget to prioritize and sustain core services when planning for new interventions (maintain prevention of mother-to-child transmission (PMTCT), condoms, linkage to treatment initiation and care from community-based active case finding, etc.)
- Plan for readiness to adopt new tools, considering country context and health systems capacity.
- While the TRP encourages ambition, be realistic and more data driven when setting targets in FRs.
- An accurate gap analysis is essential.
- Set out the right expectations about what the Global Fund allocation can achieve.
- Match Performance Framework targets with what is achievable; ambitions should match what’s been programmed (be realistic).
The TRP identified some model examples of good target-setting in W which other applicants/partners can learn from:
- Kazakhstan HIV (Focused Portfolio): There was a sharp focus on key and priority populations (KPPs), scaling up innovative interventions that have been piloted by other countries.
- Mozambique HIV-TB-Malaria: This started with a basis on the National Strategic Plan (NSP), identified what domestic funding and non-Global Fund external funding would cover, then identified what the Global Fund allocation would cover. Remaining gap went into the Prioritized Above Allocation Amount (PAAR). It was data-driven, right down to cost-effectiveness analysis directly aligned to the FR.
- Tanzania TB: There was an assessment of diagnostic infrastructure, identification of gaps, models, estimations, and a clear split between what should be covered in the allocation and PAAR.
Thematic Lesson 2: Need for greater focus on collaboration among partners at country level
The TRP was concerned by weaknesses in partnership and collaboration at the country level resulting in sub-optimal impact:
- Evidence in several funding requests indicates that in some countries, national leadership (e.g., the Ministry of Health) is not coordinating in-country partners effectively. For example, TRP observed fragmented support to national program implementation, inconsistent levels of salary for health workers, uncoordinated supply systems, some regions covered while others not.
- The Global Fund recognizes that partnerships need to include the full range of donors, civil society, and private sector. However, evidence in the FRs suggests further coordination is required to center community-led and KP organizations in programming and implementation.
- TRP’s review of the impact of Global Fund investment was often limited by an inadequate or insufficient description of activities and investments of external and domestic resources as documented in the Funding Landscape Tables/s (FLT), Programmatic Gap Table/s (PGT), and the RSSH annex.
- Private sector engagement in several FRs was noted to be sub-optimal with inconsistent mapping of private sector activities (usually disease-focused). However, the TRP noted ambition to leverage private sector for domestic resource mobilization for long-term sustainability.
|Applicants||Partners and Secretariat|
|Within the context of Global Funds investments, Country Coordinating Mechanisms (CCMs) should take a greater role in coordination of the full range of partners and ensure stewardship of national programs. To fulfil this coordination role, CCMs are advised to maintain an up-to-date mapping of donors and supported activities.||In-country partners should support capacity building of government ministries to support, guide, and engage with private sector, donors, civil society and other actors. They should also organize and support platforms that facilitate this collaboration.|
|CCMs should continue to meaningfully engage with the full range of communities and community-led organizations and ensure investment in and utilization of community-led monitoring (CLM)/civil society strengthening (CSS) interventions.||Global Fund Secretariat should continue to build the capacity of CCMs to act as a key coordination platform.|
|Future GC7 applicants are requested to provide a complete picture of investments and activities of in-country partners in existing annexes to FRs|
Thematic Lesson 3: Positive examples of strong FRs or strong areas within FRs
Across diseases and FRs the TRP noted: (I) the deliberate use of a range of national data to guide selection of interventions; and (ii) better differentiation, especially areas of focus within Focused Portfolios.
|· HIV:Increased recognition of more KPPs and more inter-sectionalism (E.g., trans and gender-diverse people, women prisoners who inject drugs).Greater prioritization and budgeting of advanced HIV disease in comparison with W1.|
|· TB:Optimization of new diagnostic tools, including rapid diagnostics, chest x-rays and CAD.Use of routine data, supplemented by research, to optimize programming.|
|· Malaria:Use of data for stratification, prioritization, and targeting interventions.More evidence of using Matchbox data to inform programming.|
|· Equity, Human Rights, & Gender:More gender and Matchbox assessments conducted with some FRs using these assessments to guide interventions.Greater recognition of punitive legal environments as impacting on access to services.|
|· Resilient and Sustainable Systems for Health:Compared to GC6, increased investments in quantity and quality of RSSH investments. RSSH investments are consistently synergistic with and complementary to C19RM investments. This is seen even when not a Global Fund RSSH “priority” country.Optimization of and investments in integrated lab systems health management information systems (HMIS) and health plan management systems (HPMS).|
Thematic Lesson 4: Variable progress on sustainability, with examples of more activity on public (social) contracting
Overall, the TRP observed greater focus on programmatic and financial sustainability in FRs:
- At a program level, examples of integration across the three diseases, beyond presentation of integrated FRs. Examples include triple elimination and some integration of HIV and sexual and reproductive health and rights (SRHR) programs.
- Greater reflection of the role of communities seen in FRs, demonstrated by the deliberate introduction of public contracting. Continuing challenges in enabling the legal structure for public contracting in some countries.
- Despite overall financing challenges, TRP is encouraged to see some examples of increasing domestic financing across countries at different points in the development continuum, including in Challenging Operating Environments (COEs)s (e.g., picking up a greater share of commodity costs).
- Promising examples of innovative financing to complement Global Fund financing e.g., synergies with multilateral investments, virtual pooling.
The TRP also noted areas for concerns related to sustainability, where more concrete steps are needed:
- Human resource sustainability remains a challenge, when TRP is seeing public sector and CHW remuneration included in funding requests with no transition plan to domestic funding.
- In some countries, lack of reliable information on domestic health expenditure (i.e., resource tracking) and inadequate planning for financial sustainability.
- Evidence of community system strengthening investments, but structural barriers remain. There were examples of countries where the legal environment (related to human rights) and regulatory systems have not been addressed effectively to ensure sustainability. In environments where certain behaviors are criminalized, some organizations cannot register or apply for funding, hindering the impact and sustainability of funding.
A trend noted under W1 continued in W2 in terms of failure to mention other partners’ activities and contributions and demonstrate how the FR interventions were linked to/complemented other efforts from partners.
The TRP presentation appeared contradictory. On the one hand, the TRP’s FR Quality Survey stated that “72% of TRP members agreed that the W2 FRs delivered strategically focused and technically sound responses aligned with the epidemiological context and maximizing the potential for impact. 26% of TRP members even went as far as to say they “strongly agreed” that this was the case. Only 2% disagreed; which was less than under W1 (5%).” This gave the impression that the majority of the applications were of good quality.
However, it then went on to highlight the issues and problem areas that required attention which are not inconsiderable and contradict the impression of the robustness of the FRs. Perhaps the lesson learnt from this is that bad news should always be preceded by positive news – !