Why Unresolved Issues Will Undermine The Impact Of Future Grants Cycle 7 Grants
The allocation of funding for the next round is underway. Countries are eagerly awaiting the allocation letters, which will provide information on the amount of funding, the proposed split among the three diseases and health system strengthening, the application process, and the implementation arrangements.
Due to the replenishment targets not being met, many fear that future grant amounts will decrease, even though scaling up interventions must take place if we are to achieve the 2030 goal of eliminating the three pandemics.
As usual, the Global Fund's motto will be to “maximize the impact of grants” and be strategic by protecting the “essentials”. The question of ‘value for money’ is at the center of the discussion, and we are all called upon to be responsible in choosing the activities that will have the greatest impact and to collectively preserve what has been hard-won after 20 years of struggle.
And indeed a lot has been achived and there is a lot to pretect.
However, the disappointing replenishment results have brought home the fact that resources are not infinite and that this may be the last time we have $15.6 billion thanks to the donors who trust the Global Fund.
But we also know that we are dragging the same unresolved issues behind us, the same counterproductive processes from cycle to cycle which hinder our performance, stifle our innovation, and prevent the expected progress. Yet we go ahead and plan to do the same thing over and over again, while expecting different results... are we mad?
There are four reasons why this happens and that must be addressed if one is to break this vicious circle.
The first enemy to achieving impact is the lack of innovation in the grants which include some long-standing interventions that we know have little or no impact on the indicators. This is mainly due to three factors: the Global Fund’s modular framework, the failure to share successful interventions, and the dearth of original and bold solutions.
The Grant Cycle 7 (GC7) documents, like those that came before, are again prescriptive in the way they guide applicants. The modular framework, which proposes predefined interventions, is both a good source of inspiration and a trap that most writing teams fall into. When used incorrectly, it is a ‘catalogue’, a meaningless ‘shopping list’, where interventions are not adapted nor complimentary to each other. The smartest applicants take the time to reflect and adapt the proposed activities to their context but often, due to lack of time and inspiration, the modular framework substitutes for the necessary discussions that stakeholders need to have about their needs, existing interventions, their successes, and failures, and what remains to be done. In too many cases, the modules and interventions are chosen before the discussions begin and stakeholders are forced to work within a narrow framework that inhibits innovation.
The other element that deters creativity is the difficulty of proposing original ideas in the process of elaborating funding requests and, especially, the difficulty of costing them. There are two main ways to propose innovative activities (innovation being defined here as the introduction of new subjects or new modus operandi):
Be inspired by what has been implemented elsewhere and which has demonstrated its added value. To be able to do this, you need to know what is being done elsewhere, have sufficient information to reflect on the conditions for adapting the approach, and know the associated costs and the actors to involve. This is needed to demonstrate that the intervention is feasible, has a chance of succeeding and to be able to accurately assess the cost. Unfortunately, the Global Fund is not a learning organization which emphasizes knowledge management so it is difficult for this information to circulate between programs in different countries. In the end, it is often the consultants who transmit these experiences from one country to another. However, since there is little time to observe what others are doing and read articles on the same, many countries miss opportunities to replicate what works elsewhere. One example is the time lost introducing pre-exposure prophylaxis (PreP), known to have satisfactory results but which, during NFM3, still raised many questions to the extent that it was introduced as a ‘pilot’ even though the evidence of its efficacy was already available.
The other way to ‘get’ innovation into grants is through programmatic ‘gambling’,?a clever mix of lessons learned from previous unsuccessful interventions, reading about what works elsewhere, and trying to change the paradigm to succeed.
One area where this innovation is needed is in the prevention of mother-to-child transmission (MTCT) of HIV in West and Central African countries. The results are disastrous, as the director of the?Children and HIV in Africa?network, reminded us: "You have barely 35% of children screened, 35% on treatment and 27% who have a suppressed viral load, which proves that there is either a problem with the medication or that it is not effective or is poorly taken”. The current focus, mainly on the HIV sites managed by national HIV programs, is limited. Additionally, the status of neonatal health in the African francophone region is acute: at the same rate as the birth rate, the growth in infant mortality is due to two main factors: asphyxia and infections.?A team of anthropologists from the IRD?(Interactive Research & Development) has demonstrated how intermingling disciplines such as anthropology, sociology and adult education is necessary to address the relationship between service use and mortality, as it seems quality is more at stake than accessibility. Mixing social sciences with health, seeking cross-cutting interventions that combine immunization services (also in disarray with a dramatic drop in routine immunization in 2021 and 2022) and maternity services with those of the fight against pandemics, therefore makes sense. This should be supported by an ambitious program to train and coach health center staff to ensure that a minimum quality of care is provided to mothers and newborn.
Due to the lack of time to describe innovation during funding request development, the inability to cost innovation, and the hesitation to promote new interventions that run the risk of failing, funding requests lack new and bold approaches that could be real game changers.
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A second unsolved topic is the payment of human resources for health (HRH) and their capacity building.
The Global Fund's rules are clear: since ministry of health (MOH) staff are already paid, it is not possible to pay them from Global Fund grants and awarding bonuses is subject to exceptions described in the?Operational Policy Manual. The reasons are readily understood: to avoid creating a system of double funding or incentives that is counterproductive in the long run, since staff become used to working with resources that will not be sustainable once the Global Fund grant ends.
At the same time, we bemoan the small number of available and well-trained HRH in developing countries’ health systems and we wonder how fair it is to sometimes ask them to put in such efforts for a salary that is known to be low at best and even unpaid at times. We all know that this system of HRH management is limited or non-existent, dysfunctional and under-funded.
The precariousness of HRH conditions partly explains the large number of workshops and unnecessary missions, readily acknowledged by civil servant colleagues who are diverted from their daily responsibilities. Instead of supporting the ministries to reform HRH management including skills management, initial and ongoing training, deployment, remuneration and bonuses, attention continues to be diverted from this major problem. This results in millions of dollars being spent on activities of questionable impact. Technical Review Panel (TRP) members said in their?review?of NFM approaches that “in COEs that have significant gaps in HRH, the Global Fund may consider well-justified requests for higher and time-limited contributions to salaries, incentives and trainings, that for instance, would help ensure effective program implementation and sustain program gains while allowing time for planned transition of responsibility to the government”.
We must urgently address HRH capacity building. We must put an end to all the training sessions that only last a few days and whose quality and content are not measured, nor their impact in terms of knowledge and skill acquisition and the evolution of the practices of those trained. Organizing workshops has become an industry, with costs unified among donors, hotel services, venue rentals and catering, per diems and transportation costs. During NFM3 funding request development, TRP members asked some countries to list all their planned training events, and the list was incredibly long. Their?conclusion?was clear: “Applicants need to look at their overall training investment more critically: while the TRP supports capacity-building, it is concerned by the number of requests for training that do not address the underlying needs, or why previous training was seemingly ineffective and not institutionalized”.
While these training workshops need to be scrutinized, the fact remains that capacity building is a real need. However, due to a lack of expertise in training and capacity building, there is little in the way of solutions to the problem of adult education in the funding applications; few ‘buddy’ approaches, mentoring, change management for the introduction of new interventions or simply new management methods. There is generally no ‘baseline’ of competencies (and most MOH departments do not have a competency framework, updated job descriptions by competency, or an effective assessment tool) that serves as a reference for assessing progress in the acquisition of knowledge and skills. This is far from the tangible results the Global Fund is calling for.
However, it is now known that no system strengthening can be conducted without human resource capacity building. Good examples exist, such as the CARPESS program developed by the Antwerp Institute of Technology (ITM) to train managers in the Moroccan MOH. Now accredited by the WHO MENA Regional Office, this program mixed traditional learning approaches with one-on-one mentoring methodologies, study tours in European countries, and an end assignment relevant to their jobs. It responded to an initial needs assessment conducted with the ministry and was developed according to the ministry's choice of modalities. This experience could be replicated and would surely meet health resources’ interests.
The response to a population’s health problems cannot ignore the importance of traditional actors, who are most often beneficiaries’ first recourse. WHO studies have shown that 80% of patients who have a health problem first turn to a traditional practitioner, then resort to self-medication (especially the purchase of medicines on the market) and going to a health center comes much later. The decision to seek care depends on complex and interconnected factors: the perception of illness and its link with traditions, the trust placed in traditional actors who are community members, the confidence placed in health institutions to solve a health problem, and the cost of this approach, particularly in rural areas where travel takes several hours and is expensive.
Although they are a major player in the non-formal health care system, traditional practitioners are ignored by many conventional caregivers, who are fighting against them with the support of many health donors. Meanwhile, the traditional practitioners benefit from the social and cultural legitimacy of the community in which they disseminate their knowledge. Their contribution to the population’s primary care coverage, especially rural populations, is important. Community actors such as community-based organizations are aware of this, and they are more willing to collaborate with traditional healers, especially for new TB case notification.?The thematic review of PMTCT in eight countries?shows that traditional birth attendants (TBAs) are poorly engaged when it comes to contributing to a mother’s HIV information and testing. Facility-based services are missing a prime opportunity to interact with TBAs. This contributes to a failure to use social norms in a positive way, and to the reluctance of some mothers to be tested and treated.
One of the reasons for this ‘ignorance’ is the absence of formal supervision or relationships between the formal health system and the traditional actors. Some countries in French-speaking Africa have provided a legal framework for the practice of traditional medicine, resulting in a legal regulatory text. This is the case for Burkina Faso, Central African Republic, C?te d'Ivoire, Equatorial Guinea, Mali, and Niger. Even if a similar framework is still controversial in countries such as Cameroon or Senegal, as a rule it seems that the difficulty lies rather in the choice of the most appropriate mechanisms to regulate the activity than in a rejection of the activity itself.
And the discussion extends, of course, to the role played by TBAs whose practice has been regulated by WHO since 1992 in the?Joint WHO/UNFPA/UNICEF Statement on Traditional Birth Attendants. Documented experiences have shown that their involvement in several tasks and their inclusion in the formal system is an indispensable bridge between pregnant women and the formal health system. In Malawi, thanks to TBAs’ training and supervision, more pregnant women have been referred to health care facilities, and the central role played by these women in the babies’ pre-delivery and post-delivery monitoring has had a very positive effect. In Rwanda, the TBA training program has contributed to decreasing maternal mortality from 750 to 290 deaths per 100,000 between 2008 and 2021. In the framework of the fight against MTCT or for the follow-up of malaria chemoprophylaxis in pregnant women, collaboration with TBAs (training, equipment, supervision, implementation of formal relations with the health centers) is a major asset that could improve the attainment of indicators.
Finally, it is a recurring discussion and common theme in the Global Fund: how to simplify procedures for committing and justifying expenditures, to save time and implement relevant and flexible interventions? In developing countries, where activities in rural areas are still important, and where tradition remains oral, 300-page procedural manuals, procurement procedures that take months, and reprogramming that mobilizes actors for only one to two quarters are all obstacles that could be avoided. Health system implementers acknowledge this without being proud of it: Global Fund financing is the last to be used because it requires too much procedural effort, and the consequences if the expenses are deemed ineligible are serious because they must be reimbursed. If in doubt, they prefer to abstain and work with more flexible and less fussy partners. The Principal Recipients in these countries are annoyed by discussions that revolve around procedures and not around the essential: the impact.
When will we stop hiding a reality that we all know? The procedures for planning, commitment, justification, and reprogramming are too cumbersome. The establishment of fiscal agencies, far from simplifying the processes and strengthening the actors involved in implementation, creates even more confusion, frustration, and blockages in implementation. Between ineligible costs and the operational cost of services that never reach patients, a responsible but clear choice must be made. For it is most surprising is to hear Secretariat staff complain about slow implementation and express surprise at bottlenecks, when the latter are the result of Global Fund-imposed procedures or those of their service providers such as fiscal agents.
In a way, the Global Fund has created a monster. Just look at the 400 pages of the OPM (only available in English by the way, and which we at GFO have criticized many times), of which we have lost control. It is time to regain that control if the countries’ grants for the next cycle are to have the expected programmatic impact.