Guide to Using Round 7 of the Global Fund to Fight AIDS, Tuberculosis and Malaria to Support Health Systems Strengthening

 

 

March 2007

 

 

 

 

 

Contents

 

Acknowledgments…………………………………………………………………………………………………………………………………4

 

I. Using This Guide………………………………………………………………………………………………………………………………5

1.      Who should use this Guide?

2.      How definitive is this Guide?

3.      Where can applicants turn for further support in developing Global Fund proposals related to health system strengthening?

 

II. Why Applicants Should Use the Global Fund to Support Health System Strengthening…………………8

1.       Overarching value of using the Global Fund to support health systems

2.       Further benefits from a system-wide, cross-cutting approach to health system strengthening

3.       Determining whether to use an integrated, system-wide or more vertical approach to developing health system components of HIV and other disease programs

 

III. What Health Systems Strengthening Measures the Global Fund Will Support………………………………12

1.      Areas of Global Fund support

2.      Can Round 7 still support significant levels of HSS even though there is no separate HSS component?

3.      What is a main HSS Strategic Action for purposes of table 4.4.2?

4.      May a proposal include more than one type of health system strengthening activity?

5.      May a proposal include only health system strengthening activities?

6.      May an applicant seek support for both cross-cutting HSS activities and more vertical health system strengthening activities?

7.      If an applicant is seeking support for health system strengthening activities, may the applicant also seek funding for HIV, tuberculosis, and/or malaria activities?

8.      Do health system strengthening activities need to be linked to the particular HIV, tuberculosis, or malaria activities included in the Round 7 proposal?

9.      Are there any requirements that people with health systems expertise serve on CCMs?

 

IV. Finding Opportunities to Support Health System Strengthening …………………………………………………17

1.      Overcoming health system constraints to reducing the spread and impact of AIDS, TB, and/or malaria

2.      Supporting an existing strategy

3.      Creating a national health plan if none currently exists

 

V. Selected Issues in Constructing a Successful Proposal……………………………………………………………………22

1.      Linking HSS Strategic Actions to the Fund’s target diseases

a.      Rwanda’s Round 5 HSS proposal

b.      Malawi’s Round 5 HSS proposal

c.       Kenya’s Round 6 TB proposal

2.      Sustainability

3.      Salaries and incentives: Several important considerations

4.      Pursuing a comprehensive approach

5.      Technical support for implementing proposals

6.      Health systems monitoring and evaluation system

 

VI. Features of Successful Global Fund Proposals on Health System Strengthening …………………………36

1.      Strong links to reducing spread and impact of target diseases

2.      Strong health system analyses

3.      National commitment and strategies

4.      Strong chance of success

5.      Pro-poor and pro-marginalized populations

6.      Support from other development partners

7.      Discrete focus

8.      Address major obstacles

 

VII. What Applicants Can Learn from the Technical Review Panel’s Comments on Earlier Proposals…38

  1. General Advice Arising from HSS-Related Proposals

1.      Detailed, realistic budgets

2.      Modest administrative costs

3.      Proposal size: feasible and not too small

4.      Sufficient details

5.      Relationship to previous grants and other sources of funding

6.      Realistic indicators

7.      Realistic pace of activities

8.      Principal recipient capacity

9.      Proposal coherence

10.   Added value for regional proposals

11.   Capacity to manage significant scale-up

  1. Health System-Specific Strengthens and Weaknesses

1.      Careful health systems analysis, including gaps

2.      Health system element details

3.      Strategies likely to succeed – demonstrating feasibility

4.      Meaningful community participation

5.      Integrated approach for addressing target diseases

6.      Integration into health system strengthening strategies

7.      Inclusion of non-government sector

8.      Evidence of success

9.      Support for rural/deprived areas

10.   Limited focus on workshops, meetings, and research

11.   Salaries consistent with national standards

12.   On-site training where possible

13.   Length of training should reflect position responsibilities

14.   Avoid creation of highly vertical programs

 

VIII. Resources……………………………………………………………………………………………………………………………………………46

1.       Publications related to the Global Fund and technical support

2.       Selected resources on human resources for health

 

Acknowledgements

 

Eric A. Friedman, JD, Senior Global Health Policy Advisor for Physicians for Human Rights (PHR), wrote this Guide.  He can be reached at efriedman@phrusa.org.

 

The author is especially grateful for the research and editing assistance of Eric Liao, MD, as well as the research assistance of Virginia Triant, MD, MPH, Fellow in Infectious Diseases, Massachusetts General Hospital and Brigham and Women’s Hospital, for research assistance in preparing the earlier version of this Guide.  For reviewing and commenting on this updated Guide, the author thanks Sarah Kalloch, PHR Senior Coordinator, Health Action AIDS Africa Program, Barbara Ayotte, PHR Director of Communications, and Maggie Cooper, PHR Health Action AIDS Policy Associate.  For help in distributing this Guide, thank you to Amanda Cary, PHR Health Action AIDS Staff, Ben Greenberg, PHR Web Community Coordinator, and PHR interns Sabina Carlson and Faythe Mallinger.

 

For reviewing and commenting on the previous edition of this Guide, contributions that are still reflected in the present version, the author thanks Nicholas Leydon, former Health Action AIDS Program Associate for PHR, Barbara Stilwell, PhD, FRCN, former Coordinator, Performance, Improvement and Education, World Health Organization (WHO), and Phyllida Travis, MD, Health Policy, Development and Services, WHO. 

 

Feedback on this Guide is appreciated, and should be directed to the author.

I. Using This Guide

 

1. Who should use this Guide?

 

This Guide is intended to assist members of Country Coordinating Mechanisms (CCMs) and others involved in preparing proposals for Round 7 of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.  This Guide provides assistance in thinking about and developing proposals that include health system strengthening activities.  It might also help motivate countries to use the Global Fund to support such activities.  Physicians for Human Rights (PHR) encourages civil society to engage their countries’ CCMs about ways to include HSS in their proposals to the Fund, and hopes that the information provided in this Guide will support civil society in these efforts.

 

2. How definitive is this Guide?

 

The advice in this Guide is primarily drawn from analysis of successful Round 5 Health Systems Strengthening (HSS) proposals and Round 6 proposals with significant HSS elements, along with comments by the Technical Review Panel (TRP), the independent experts who review Global Fund proposals and recommend which ones the Global Fund Board should approve.  PHR reviewed TRP comments on unsuccessful Round 5 HSS proposals and Round 6 proposals, though the full proposals were unavailable.

 

The advice provided in this Guide is meant to cover a variety of country circumstances, yet much will depend on the particular nature and goals of each proposal and the situation of each applicant.  Applicants should consider how the advice and analysis in this Guide apply to their particular circumstances.  This Guide is intended to supplement, not replace, other forms of support. 

 

The advice and information contained in this guide is formed by careful analysis, but the final decision lies with the TRP. This Guide has not been reviewed or endorsed by the Global Fund.

 

3. Where can applicants turn for further support in developing Global Fund proposals related to health system strengthening?

 

PHR urges applicants to consider contacting the World Health Organization (WHO) or other sources of technical expertise as needed.  Indeed, the Round 7 Guidelines themselves “strongly” encourage applicants “to work with technical partners with specific experience on health systems strengthening during proposal development.”[1]

 

Applicants can contact their country’s WHO Country Office.  In addition, the following are entities that are available to offer technical support in developing HSS-related Round 7 proposals.  This is a partial list; other organizations are very likely also available to provide technical support.

 

 

 

 

 

 

In addition, the following entities are able to assist countries with HSS-related support needed to overcome bottlenecks to implementing of existing Global Fund grants.

 

 

 

 

 

 

 

 

 

If applicants have questions related to the Global Fund proposal process, PHR suggests that they contact country Global Fund portfolio managers.  The name and email address can be found on the country page on the Global Fund website: http://www.theglobalfund.org.

 

PHR strongly encourages countries to draw on all available resources, especially local experts, to ensure that proposals are technically sound, and to seek external support where needed.


II. Benefits of Using the Global Fund to Support Health System Strengthening

 

This section discusses a number of benefits of incorporated health systems strengthening in Global Fund proposals.  It begins with overarching values of using the Fund to support HSS, and then provides a number of benefits of using the Fund to support system-wide approaches to health systems strengthening.  It concludes with an examination of several points to consider when deciding whether to use a more vertical or system-wide approach to addressing health systems strengthening.

 

1. Overarching value of using the Global Fund to support health systems

 

a. Enabling HIV, tuberculosis, and malaria programs to succeed

 

In many countries, weak health systems are a central obstacle to successfully scaling-up and sustaining HIV, tuberculosis, and malaria programs.  The Global Fund represents an opportunity to remove these obstacles and create enormous benefits for those affected by the Fund’s three target diseases.

 

b. Helping fulfill obligations to highest attainable standard of health

 

Using the Global Fund to strengthen health systems to reduce the spread and impact of HIV, tuberculosis, and malaria will help many countries fulfill their human rights obligations, in particular the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health.”[2] Under international law, states are obliged to take steps “to the maximum of [their] available resources,” including resources available through international assistance, to progressively realize the right to the highest attainable standard of health.[3]  By taking maximum advantage of the Global Fund’s financial resources to strengthen the national health system and improve the health of the population, states demonstrate their commitment to a universal right to health.

 

Well-designed Global Fund proposals also provide an opportunity for states to take an important step towards realizing one of their core obligations under the right to the highest attainable standard of health: meeting the needs of poor, rural, and other marginalized populations.[4]  Health system strengthening activities included in Global Fund proposals should be designed with a particular emphasis on these populations.

 

2. Further benefits from a system-wide, cross-cutting approach to health system strengthening

 

Strengthening activities may be tied to a particular disease (e.g., developing an information system for HIV/AIDS programs) or system-wide, cross-cutting activities (e.g., strengthening the national health information system) that benefit not only a particular disease program but also a wide range of health priorities.  Activities may also fall in the middle and benefit several health priorities including one of the Fund’s target diseases; examples might include integrating reproductive health with HIV services, or maternal and child health care with programs which prevent mother to child HIV transmission.  The following paragraphs will briefly examine the numerous benefits of a system-wide approach.  At times, however, urgency of need may dictate a more vertical, disease-specific approach.  This is considered at the end of this chapter in more detail.

 

a. Benefiting other health priorities

 

In addition to supporting HIV, tuberculosis, and malaria programs, system-wide strengthening can benefit other health priorities.  By strengthening health workforces and other basic health system elements, applicants can address an array of health areas and create a workforce able to provide a range of health services, helping countries to reach the Millennium Development Goals and other health targets. For example, greater health worker density has enabled countries to increase coverage of measles vaccinations and skilled health workers attending births,[5] thereby reducing maternal mortality.

 

b. Avoiding harm to other health priorities

 

In nations without an adequate supporting infrastructure, scaling up programs to address individual diseases creates an additional burden on a limited workforce and risks harming efforts to address other health priorities, unless support is provided to the system to enable it to successfully handle these additional programs.  Countries with severe health worker shortages may be unable to scale up disease-specific programs without drawing health workers away from other health services.  Or new or expanded programs may further stress already overworked health workers, possibly compromising quality of care delivery and rendering them more likely to leave the country’s health services.[6]

 

Even singling out disease-specific programs for special benefits poses risks.  If only health workers associated with these programs receive financial incentives to promote their retention, health workers not receiving these incentives may feel that they are being treated unfairly.[7]  This may lower their morale and lead to reduced quality of care and staff attrition.  A system-wide approach minimizes such harm to other health services and can benefit them instead.

 

c. Integration of health services

 

Pursuing a system-wide approach supports the integration of health services rather than developing a parallel, disease-specific infrastructure that duplicates existing delivery systems and wastes scarce resources.  For example, duplicate procurement and distribution systems require staff to manage multiple mechanisms for drug ordering, more complex information systems, and duplicate warehouses and distribution systems.[8]

 

Although developing parallel infrastructure may be faster and possibly less expensive in the short term, over time a unified system will result in greater efficiency and sustainability, while the investments to strengthen this system may also benefit other health services.  Recently, Ethiopia chose to develop its existing procurement and distribution system to handle anti-retroviral medications and drugs for opportunistic infections rather than construct a parallel system. Initially this led to slow procurement and a period of adjustment, but Ethiopia adapted and began “renting more warehouses, hiring more staff on short-term contracts, and contracting out specific elements of the procurement and distribution chain… [resulting in] very positive effects upon the efficiency of procurement.”[9] This is especially critical for HIV.  Securing ARVs for all is both an emergency and a lifelong commitment by governments, and needs to be backed by functioning systems for the long-term, making this type of HSS integration imperative.

 

d. Meeting essential needs

 

Finally, in some cases, a system-wide approach is the only way to meet needs.  Rwanda’s and Malawi’s Round 5 HSS proposals are both good examples.  Realizing that its human resource shortage was too severe to resolve only on a disease-specific basis, Malawi secured a Global Fund grant that included system-wide measures to retain health workers and expand its capacity to train new health workers.  Rwanda recognized that overall low utilization of health services was an obstacle to the success of its AIDS, tuberculosis, and malaria programs, so it proposed measures to encourage utilization by improving overall access to health services.

 

3. Determining whether to use an integrated, system-wide or more vertical approach to developing health system components of HIV and other disease programs

 

This section provides a perspective on the sometimes difficult question of whether to use a more vertical or integrated, system-wide approach to health system strengthening.

 

The potential to benefit programs for the target diseases along with other health needs, while avoiding duplication and enhancing the prospects for long-term sustainability, favors a system-wide approach.  Yet this approach can have costs.  Particularly where the current system is fragile, changing that broader system or particular system elements (such as a drug distribution system) may take time, which may delay the delivery of urgently needed disease-specific interventions.  In some cases, then, pressing needs may lead to a decision to utilize a more vertical approach.

 

In determining whether to pursue a vertical or integrated approach, program designers and other stakeholders should first analyze the country’s circumstances.  At a May 2006 meeting in Cape Town, South Africa, a meeting of AIDS advocates, health systems experts, health officials and workers, and people living with HIV/AIDS agreed that countries should undertake “an explicit assessment and evaluation of which components…can be integrated into general health systems and which require vertical implementation in the short to medium term.”[10]  If a vertical approach is chosen for the short-term, specific plans should be made “for integrating all vertical components into the general health system in the medium and long term.”  Finally, program planners should consider possible unforeseen consequences of their approach and “include contingency strategies to address potential problems.”[11]

 

In addition, if an effective parallel system is established to bypass a poorly functioning element of the national system, successful practices should be applied to the national system so that the parallel system can ultimately be integrated into the national system.  For example, Kenya developed an Emergency Hiring Plan to rapidly hire into rural areas 830 additional health workers through a process that is distinct from the Ministry of Health recruitment process.  Those hired through this process have praised its speed and fairness.[12]  Lessons learned from this parallel system should be incorporated into general government recruitment procedures. 

 

The Global Fund recognizes the potential dangers of vertical programs. The Technical Review Panel has specifically expressed its concern about vertical programs that risk harming the overall health system.  In comments on Round 6, the TRP reported to the Board of the Global Fund that applicants should “be guided not to propose activities that will build strong vertical systems at the obvious expense of the broader healthcare system…[such as] by attracting staff away from [other elements of the healthcare system], or by developing an entirely vertical disease program in isolation from the remainder of the healthcare system.  The TRP is critical of such approaches, and would not recommend them for funding.”  The TRP’s expectation is that proposed HSS activities “strengthen, or at a minimum, not undermine the broader healthcare system.”[13]

 

The Proposal Form specifically asks applicants to state how proposed HSS Strategic Actions will impact performance of the health system, and to describe “any risk mitigation strategies in response to potential threats to the health system.”[14]  Further, the Guidelines explain that a comprehensive justification for funding HSS Strategic Actions will explain how approaches “clearly build on existing systems, structures and processes, and not parallel ones.”[15]
III. What Health Systems Strengthening Measures the Global Fund Will Support

 

This chapter explains the fundamental requirement for seeking Global Fund support for HSS and describes the wide range of HSS activities for which applicants may seek support.  It then addresses some basic questions about the extent to which proposals may include HSS, the relationship of HSS activities to the proposal’s disease-specific activities, and the health systems capacity of CCMs.

 

1. Areas of Global Fund support

 

The fundamental requirement in applying for HSS activities, what the Round 7 Guidelines describe as “HSS Strategic Actions,” is that they are “essential to reducing the impact and spread of any or all of the three diseases.”[16]  There is little restriction on supported HSS activities, as long as applicants can demonstrate that those activities are needed to advance the fight against HIV/AIDS, tuberculosis, and/or malaria. The only HSS activities that the Global Fund will clearly not support are large scale infrastructure investments, such as building hospitals and clinics, although applicants may seek funds to rehabilitate existing health facilities.  As the Guidelines state, accepted activities may fall into the following areas:

 

·         Governance

·         Strategic planning and policy development

·         Monitoring and evaluation

·         Coordination/partnerships

·         Community and client involvement

·         Policy research

·         Information systems

·         Health management

·         Health financing

·         Human resources

·         Essential medicines and other pharmaceutical products management

·         Procurement systems

·         Logistics, including transport and communications

·         Infrastructure (but does not include large scale investments, such as building hospitals and clinics); and/or

·         Technology management and maintenance.

 

Activities need not fall within the health sector.  The Guidelines further explain that as long as applicants demonstrate the fundamental link between the actions and reducing the spread and impact of at least one of the Fund’s target diseases, these actions may also be in other sectors, such as education, the workplace, and social services.[17]

 

Global Fund grants in Rwanda, Malawi, and Haiti illustrate the breadth of activities that can be covered.  Through its Round 5 grant, Rwanda will provide electricity to health centers in six provinces and fund a community-based health insurance strategy, having convincingly linked these actions to improving utilization of health services for the Fund’s target diseases.  In Haiti, Partners In Health re-allocated a portion of its Round 1 funds to purchase essential drugs for a rural clinic, successfully arguing that improving the quality of health services would increase patient utilization and thereby increase provision of HIV services.[18] Malawi received Round 5 funds to finance a portion of its Emergency Human Resources Strategy to increase health workforce capacity, including through expanding its pre-service training capacity and hiring 5,228 community-based health workers (including more than 1,000 community nurses) to help implement Malawi’s Essential Health Package, which includes interventions for HIV/AIDS, malaria, tuberculosis, and other diseases.

 

2. Can Round 7 still support significant levels of HSS even though there is no separate HSS component?

 

Yes.  Even though the Global Fund does not have a separate HSS component this Round, the “HSS window” remains open. The separate HSS component was removed after Round 5, but proposals that robustly address cross-cutting health system strengthening needs remain possible.  The change in format requires proposals to be structured differently, as HSS activities must be included in one of the disease component.  The activities included in the successful Rwanda, Malawi, and Cambodia Round 5 HSS proposals would have been possible to include Round 7. 

 

The Round 7 Guidelines and Proposal Form do present one new limitation.  Applicants may describe up to five “main HSS Strategic Actions that are essential to ensure that the planned outputs and outcomes of their Round 7 proposal will be achieved” in table 4.4.2.[19]  Applicants may add additional HSS activities in section 4.6 of the Proposal Form, as well as the Work Plan in that section, and the budget in section 5 (activities for the main HSS Strategic Actions should also be included in these other sections).  A proposal that includes more than five main HSS Strategic Actions risks being rejected by the TRP. 

 

This limit is not as restrictive as it may appear, and still allows for major and varied health system support.  For example, Rwanda’s successful Round 5 HSS proposal extended community-based health insurance to the half of its population that had not already been covered.  This action, which will receive $27 million from the Fund over five years, likely would be considered a single HSS Strategic Action.[20]

 

If applicants find that this restriction to five HSS Strategic Actions prevents adequately addressing major system weaknesses, PHR recommends that they provide feedback to the Global Fund, in particular to the applicant’s Country Portfolio Manager, along with the request that this feedback be sent to the Secretariat in Geneva.  PHR would also be interested in hearing this feedback; please contact the author of this Guide.

 

3. What is a main HSS Strategic Action for purposes of table 4.4.2?

 

Please note: This section III.3 is based on PHR’s best understanding of a “main HSS Strategic Action” as described in the Guidelines.  This analysis should not limit applicants’ considerations.  This understanding has not been confirmed by the Global Fund, and unlike most of the areas in this Guide, information from earlier rounds is not available to root the meaning of a single HSS Strategic Action. We therefore encourage applicants to work with technical partners to develop an understanding of what counts as a single HSS Strategic Action in their circumstances, and if needed, to consult their country’s Global Fund portfolio manager if further clarification is needed.

 

The HSS Strategic Actions to be included in table 4.4.2 represent significant sets of activities, ones that are “essential to the intended disease-specific performance outcomes under the proposal.”[21]  Each of the HSS Strategic Actions may be substantial enough to have other sources of funding being provided to support that action, and each action may have multiple outcomes and outputs. 

 

The Round 7 Guidelines present two examples of HSS Strategic Actions:

 

·         an information technology system is to be developed to assist the recording of treatment of HIV/AIDS, malaria and tuberculosis at the district health level; and

·         the rehabilitation/refurbishment of testing clinics for HIV/AIDS and tuberculosis.[22]

 

These suggest that an HSS Strategic Action may be thought of as a related set of activities aimed at a common health system goal that is related to at least one of the Fund’s three priority diseases.  For example, the HSS Strategic Action on developing an information technology system might include a variety of activities – such as purchasing computers, developing software, and training health workers and managers in using the system – aimed at the goal of recording treatment of HIV/AIDS, tuberculosis, and malaria.  Rehabilitation of testing clinics might also include a number of activities – such as providing clinics with electricity, microscopes and other laboratory equipment, expanded waiting rooms, and maintaining the equipment and facilities – aimed at the goal of increasing the number of clinics able to test for HIV and tuberculosis.

 

The following are possible examples of HSS Strategic Actions.  These examples should in no way constrain applicants in determining what, in their particular context, would be considered an HSS Strategic Action, what such actions applicants should apply for, or what activities should be included in a particular HSS Strategic Action.  Technical partners may be able to assist in such determinations.  Other examples of HSS Strategic Actions may be:

 

 

As described more below in section V.4, applicants should explain how their approach to health systems strengthening in a particular areas or areas addressed in the proposal represents a comprehensive approach or how it is part of a comprehensive approach or functioning system.

 

4. May a proposal include more than one type of health system strengthening activity?

 

Yes.  Proposals may include up to five main HSS Strategic Actions, and applicants have discretion on how to allocate these actions among the various health system areas.  One HSS Strategic Action might address human resources for health, another might improve financial access to health services, and a third might improve drug distribution logistics.  Countries should not apply for more activities than they can anticipate successfully implementing.  If the TRP believes that a proposal is infeasible, it will almost certainly reject it.  The fundamental requirement described above of linking the HSS Strategic Actions to reducing the spread and impact of at least one of the target diseases must be met for each HSS Strategic Action.

 

5. May a proposal include only health system strengthening activities?

 

Yes, there is no requirement that a proposal include non-HSS activities.  Kenya’s Round 6 TB proposal was focused entirely on cross-cutting health system strengthening activities;[23] its four objectives all addressed health system weaknesses that hampered TB/HIV service delivery.[24]  If a country’s CCM determines that it does not need additional support for disease programs, it could apply only for health system strengthening, as long as the applicant can establish that system weaknesses are a barrier to the success of disease programs, and can convincingly link strengthening to achieving success. 

 

The Round 7 Guidelines acknowledge this possibility.  It recognizes that a proposal may be “predominantly, a request for funding for HSS Strategic Actions to support a national program which already has significant existing or planned resources to reach program needs,” while emphasizing the importance of ensuring “that the overall program goal(s) and objectives are expressed in a manner which demonstrate the clear and essential link between the funding requested for the HSS Strategic Actions and the disease specific national plan for scale up of services.”[25]

 

6. May an applicant seek support for both cross-cutting HSS activities and more vertical health system strengthening activities?

 

Yes, proposals may include both system-wide and more targeted health system strengthening activities. Malawi’s Round 5 proposal supported system-wide human resource activities such as expanding the capacity of pre-service training institutions while also supporting the recruitment and retention of health workers needed at ART clinics.  PHR encourages applicants to consider the benefits of system-wide strengthening and integrating disease-activities with other health services, as discussed above.  PHR also reminds applicants that the Round 7 Guidelines encourage approaches “that clearly build on existing systems, structures and processes, and not parallel ones.”[26]  The TRP has expressed its preference for proposals that contribute to broader health system strengthening, or at the very least do not harm the overall system.

 

7. If an applicant is seeking support for health system strengthening activities, may the applicant also seek funding for HIV, tuberculosis, and/or malaria activities?

 

Yes, Round 7 proposals may include up to three proposal components, one for each target disease.  System strengthening activities may be included in any or all of these components and do not preclude applying for any other activities.  They may represent a small or large portion of funds sought.

 

8. Do health system strengthening activities need to be linked to the particular HIV, tuberculosis, or malaria activities included in the Round 7 proposal?

 

No.  Strengthening may be needed to scale-up or sustain HIV/AIDS, tuberculosis, or malaria activities that are being pursued outside the context of the Round 7 proposal.  Requests to support such activities are perfectly acceptable and would be unrelated to the disease-specific activities included in the proposal.  For example, the application may include health systems strengthening activities required for malaria treatment when the only malaria-specific activities in the proposal relate to distributing bednets.

 

9. Are there any requirements that people with health systems expertise serve on CCMs?

 

Not precisely, but for the first time, the Guidelines expressly ask CCMs about their capacity to understand health system needs.  Proposals must now explain how their CCMs (or Regional Coordinating Mechanisms) “have, or are developing and/or strengthening, their capacity and experience in the identification of strengths, weaknesses, threats and opportunities in the health system . . . .” [27] Those applicants who submitted a Global Fund proposal in Round 6 are also asked to describe improvements in the CCM capacity to address health system issues.

 

This new requirement provides additional reason for CCMs to reach out to individuals and organizations with health systems expertise.

IV. Finding Opportunities to Support Health System Strengthening

 

In considering the use of the Global Fund for health system strengthening, applicants can look at opportunities to apply for health strengthening from at least three perspectives.

 

 

These all represent excellent opportunities for using the Fund to support health systems strengthening. 

 

1. Overcoming health system constraints to reducing the spread and impact of AIDS, TB, and/or malaria

 

When developing their proposal, applicants should consider the range of HIV/AIDS, tuberculosis, and malaria services needed and the health system constraints on delivering those services to all people in need of them.  Applicants should bear in mind national strategies for achieving these goals, as well as commitments such as universal access to HIV services by 2010.  What are the HSS constraints to initiating, scaling up, and sustaining interventions to reduce the spread and impact of the target diseases, both current and anticipated constraints, and what are constraints to successful grant performance, both previous Global Fund grants and other activities included in the Round 7 proposal?[28]

 

While the HSS activities that may be included in the proposal are not at all limited to those required for successful implementation of disease-specific interventions in the Round 7 proposal, it is important that applicants analyze Round 7 proposal goals and consider how health systems must be strengthened to achieve those goals.  It is critical that such health systems strengthening be included in the proposal to enable it to be successful.  The TRP will very likely be skeptical of the feasibility of a proposal that identifies system constraints to disease-specific activities, but then fails to explain how the constraints will be addressed. 

 

What are the health system constraints that must be overcome?  What HSS activities will be necessary to initiate new activities in the target disease areas or ensure that current programs can succeed?  What will be needed to scale up these programs as rapidly as possible, ensure their quality, and sustain progress?  What new barriers might emerge as the programs continue to expand?  These and other such questions will help shape the proposal.  The following several paragraphs clarify two circumstances that are types of constraints around which HSS Strategic Actions may be developed.

 

a. Avoiding harm to fragile infrastructure


A constraint exists if implementing disease-related activities would come at the expense of the broader health system.   For example, as a result of a human resource shortage, the only way for a country to achieve ART targets may be to draw health workers away from other health care services, thereby harming these other health services.[29]  Applicants may seek support from the Fund to overcome such constraints.

 

b. Building capacity for the future

 

A lack of long-term capacity can put the sustainability of HIV, tuberculosis, and malaria programs at grave risk.  In addition to activities that meet immediate needs, the Global Fund also allows support for applicants in building capacity for the future, as long as applicants can demonstrate that such actions are required for the longer term success of efforts to reduce the spread and impact of the target diseases. In Round 5, Malawi proposed expansion of health professional pre-service training capacity “to have adequate numbers of qualified staff for the future.”[30]  The TRP agreed that this was appropriate, noting that one of its strengths was that it “address[ed] both the immediate need to deliver services [and] the longer term need to build capacity to train the next generations of workers.”[31]  In Round 6, Mozambique received funds to expand its pre-service training for basic and middle level health professionals, including support for training 510 basic level and 11 middle level health professionals.[32]

 

As described more below in section V.4, the Global Fund is interested in seeing that countries take a comprehensive approach to health system strengthening.  Therefore, while the TRP was quite receptive of Malawi’s request to help meet its longer term health workforce needs, the TRP might be more skeptical of a proposal that seeks to meet a country’s longer term needs when no strategy was in place to address more immediate needs.

 

2. Supporting an existing strategy

 

Limited funding may prevent the implementation of existing health sector strategies.  The Global Fund can help fill those funding gaps, where such funding is necessary to overcome constraints in advancing efforts to fight AIDS, tuberculosis, and/or malaria.  PHR encourages applicants to develop HSS Strategic Actions that are based on existing strategies.  This will ensure that these actions are harmonized with other health sector activities and part of a coherent and comprehensive approach (assuming existing strategies are of good quality), and thus most likely to be effective and to contribute to broader health system strengthening.  Also, this will ensure that they are consistent with the national health sector development plan and its timeframe, which the Round 7 Guidelines encourage.

 

If it is not possible to address constraints through an existing strategy, applicants may develop targeted interventions to address the constraints.  They might also scale up pilot projects or replicate interventions that have been successful in other countries, if circumstances are sufficiently similar and local conditions are considered in tailoring the intervention to fit the country context.  If HSS Strategic Actions are not part of an existing, comprehensive plan, applicants should describe how these actions are part of a functioning system or comprehensive approach, as requested by the Guidelines.  

 

These investments may be made through a common funding mechanism.  Applicants should see section 4.3.5 of the Round 7 Guidelines for more details.

 

3. Creating a national health plan if none currently exists

 

The Global Fund represents an opportunity to support the development of national health sector plans, comprehensive plans at the district or provincial level, or plans that cover a particular element of the health system, such as human resources for health.  Such plans have many benefits.  They can:

 

 

Technical and other financial support may be needed to develop a national plan.  The Global Fund, which can support strategic planning and strategy development, can help finance this support,[33] as long as applicants can demonstrate the necessary link between developing these plans and reducing the spread and impact of target diseases.  Applicants might argue that the development of a plan is necessary for ensuring a comprehensive, coherent response to health system constraints to addressing the target diseases, and to ensure that their national response to the Fund’s target diseases will contribute to broader health system strengthening.[34]

 

Applicants can also argue that a comprehensive health sector plan can help ensure that health sector investments promote equity and address needs of marginalized populations (and applicants should ensure that their plans do so).  Previous TRP comments have indicated the TRP’s support for equity, and the Guidelines express the Fund’s support for “equitable, efficient, sustainable, transparent and accountable health systems.”[35]

 

When developing health sector plans, countries should involve members of civil society, health workers, and other stakeholders in the planning process.  Such participation will help ensure the successful implementation of the plan, can build trust among health system users and health workers, and can help ensure that the plan meets the population’s health needs, including the needs of poor and other marginalized populations.  Applicants should explain in their proposal mechanisms to provide for genuine participation in the planning process.  The Guidelines state, “Proposals should . . . when relevant and appropriate, seek to establish mechanisms for civil society and other stakeholders in the health system to have a voice in developing policies to strengthen health and community organization systems, and to take part in interventions to this effect.”[36]

 

The Global Fund has previously supported planning.  Cambodia’s successful Round 5 HSS proposal focused largely on planning, including better linking Global Fund planning to the Ministry of Health’s core strategic planning processes, strengthening linkages between health system planning and financing, and strengthening technical planning capacities for health.  In Round 6, Kenya received funds to train “district health management teams in the development of integrated, comprehensive and implementable district health plans with a robust monitoring and evaluation system.”[37]  This training is expected to enable all districts in Kenya to have good quality and comprehensive health plans by the end of the five-year grant.  To our knowledge, however, no country has yet used Global Fund assistance to develop a costed, operational human resource plan, or such a plan for another health system element, or for the health sector overall.

 

a. Developing a comprehensive human resources for health plan

 

Developing human resources plans, along with specific strategies and budgets to implement the strategy, is an important step in beginning to overcome the health workforce crisis that constrain many countries burdened by AIDS, tuberculosis, and malaria.  Indeed, African Union health ministers committed to “[p]repare and implement costed human resources for health development plans” in the October 2005 Gaborone Declaration on a Roadmap Towards Universal Access to Treatment and Care.[38]  Round 7 could provide the funds to begin to meet this commitment.

 

Such plans are most likely to be successful if a core leadership team meets regularly to help develop the plan and ensure that it is implemented, if there is a consensus-building process among stakeholders, and if a clear monitoring and evaluation strategy is developed to ensure that adjustments are made as necessary.  Enabling a wide range of stakeholders to participate throughout this process is pivotal both to the plan’s success and as a matter of human rights, specifically the right of people to participate in decisions related to their health.[39]  Physicians for Human Rights is producing a guide on using a human rights framework in developing a health workforce plan.[40] 

 

WHO and several partners have also developed an HRH Action Framework to assist with health workforce planning.  It is available at: http://www.capacityproject.org/framework/.[41]

 

Applicants may also wish to lay the groundwork for a successful health workforce plan by seeking funds to support activities that can help ensure an evidence-based plan.  In Round 6, Kenya did this by planning studies on factors that influence health worker motivation and by carrying out TB/HIV workload assessments.  Applicants may consider studies in related areas, such as those influencing health worker migration and rural retention, or they may wish to conduct overall workload assessments, that cover but are not limited to the Fund’s target diseases.

 

V.