The Prospective Country Evaluation is an embedded mixed-methods evaluation platform designed to examine the Global Fund business model, investments and contribution to disease program outcomes and impact in eight countries. Findings were synthesized across the 8 countries to provide timely and actionable recommendations to support program improvements and accelerate progress towards the objectives of the Global Fund 2017-2022 Strategy.
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Prospective Country Evaluation 2019 Synthesis Findings
1. THE GLOBAL FUND
PROSPECTIVE
COUNTRY EVALUATION
Synthesis of Findings from 2018
Cambodia, Democratic Republic of the
Congo, Guatemala, Mozambique, Myanmar,
Senegal, Sudan, and Uganda
2. STRUCTURE OF
PRESENTATION
Purpose and approach
Methods
PCE focus in 2018
Key findings and recommendations
• Business model
• Human rights, key and vulnerable populations, gender
• Resilient and sustainable systems for health
• Sustainability, co-financing, and transition
• Value for money
Added value of the PCE
• How are findings being used in PCE countries
• Lessons learned
PCE plans for 2019
4. Evaluation of the Global Fund
business model, investments
and contribution to disease
program outcomes and impact
in eight countries
Generation of timely evidence to
support programme
improvements and accelerate
progress towards the objectives
of the 2017-2022 Strategy
PURPOSE APPROACH
Disease results chains explore
links between Global Fund
inputs, outputs, programme
outcomes, and impact.
Programmatic changes to be
observed through tracking key
indicators.
Theory-based approaches and
related evaluation frameworks
explored how and why Global
Fund investments, policies and
practices influence disease
impact pathways in the results
chains
6. Quantitative results led to qualitative exploration and vice versa
principally through the results chains analyses
Evidence triangulated and strength of evidence ranked across
findings
MIXED METHODS
Impact assessment
• Existing or modelled
secondary data
• Analysed retrospective sources
to provide context and trends
Process evaluation
• Document review, meeting
observations, key informant
interviews, root cause analyses,
process mapping
8. FOCUS OF PCE
Building on analysis of funding
request and grant making phase in
2017, 2018 focused on early
implementation of 34 grants in eight
countries, totalling over $2.1 billion
in investments during this allocation
Tracked how Global Fund
investments translated into
activities and programmatic
outputs
Identified how the business model
enabled and constrained early
grant implementation
Examined the efficiency and
effectiveness of early grant
operationalisation
9. PCE Portfolio Characteristics and 2018-2020 Grant Budgets
Source: Approved 2018-2020 budgets in $USD.
* Income category shifted between 2017 and 2018 Global Fund eligibility lists
Sudan (Lower LMI)
• Core portfolio
(formerly high impact)
• Grants total: $128.4m
• COE
Myanmar (Lower LMI)
• High impact portfolio
• Grants total: $321.5m
• Matching funds
Cambodia (Lower LMI*)
• High impact portfolio
• Grants total: $98.4 m
Uganda (LI)
• High impact portfolio
• Grants total: $478 m
• AGYW priority country
• Intensive support for
human rights (all)
• Matching funds
• CCM evolution
Mozambique (LI)
• High impact portfolio
• Grants total: $523m
• AGYW priority country
• Intensive support for
human rights (HIV, TB)
• Matching funds
• CCM evolution
Guatemala (Upper LMI)
• Core portfolio
• Grants total: $38.2 m
• CCM evolution
Senegal (LI*)
• Core portfolio
• Grants total: $73.1 m
• Intensive support for
human rights (HIV)
• Matching funds
DRC (LI)
• High impact portfolio
• Grants total: $542.9 m
• COE
• Intensive support for
human rights (HIV, TB)
• Matching funds
• CCM evolution
10. KEY FINDINGS &
RECOMMENDATIONS
Business model
Human rights, key
and vulnerable
populations, gender
Resilient and
sustainable systems
for health
Sustainability,
transition and
co-financing
Value for money
12. KEY FINDINGS:
Business Model
The Secretariat approved the majority of PCE
grants on time
First disbursements (Global Fund to PRs) for
the majority of grants were made on time
Approval processes for Matching Funds were
aligned with main grants in some cases
Country Teams allowed flexibilities which
helped with grant transition
Country Teams played important roles in
resolving early bottlenecks
Some grant start up
processes worked well and
as intended
13. Concurrent business model-related
processes reduced time and attention from
grant start up including for program
continuation grants
PR transition created initial implementation
delays
Lengthy selection and contracting of
implementers, particularly Sub-Recipients by
Principal Recipients delayed activity
implementation
Some Matching Funds approvals and
disbursements were mis-aligned with main
grant approvals and this impacted on activity
implementation
However, some processes
worked less well and this
affected grant
implementation efficiency,
contributing to delays and
low early absorption rates in
most PCE countries
FINDINGS: Business Model
15. Budget absorption for Q1
and Q2 PUDRs 2018
highly variable but low
overall:
• HIV: 14%
• TB: 47%
• Malaria: 30%
• RSSH: 7%
Despite this, our
qualitative data suggests
that core services (e.g.
treatment services
provided by national
programs) did not stop
between grants
Q3/Q4 absorption is
expected to be higher
FINDINGS:
Business Model
16. Reflecting that the provision
of core services did not stop
between grants, the
majority of countries are
meeting or nearly meeting
performance indicators
• HIV: 79%
• TB: 96%
• Malaria: 80%
This is primarily due to
performance indicators
being focused on coverage,
outcome and impact
metrics that relate to the
overall national program
(rather than grant)
performance
FINDINGS: Business Model
17. There is limited/no correlation between financial data on short-term budget absorption
and programmatic M&E data
The reliance on imperfect quantitative financial and programmatic M&E data:
Leads to inaccurate grant ratings;
Creates perverse incentives to implementers; and
Poses a risk to Secretariat grant oversight and Board governance functions
While an over-emphasis on absorption for monitoring grant performance has
drawbacks, it remains an essential first condition for grant impact. Low early absorption
is reflective that budget execution rates should be more carefully anticipated
The lack of reported data on grant-specific outputs (except in some cases) and data at
the sub-national level fundamentally compromises analysis and measurement of VfM
and could hamper efficient portfolio management
FINDINGS: Business Model
18. The Global Fund Secretariat should
Consider flexibilities to the three-year grant cycle to facilitate smoother transition between
grants, facilitate early grant implementation and enable adequate time for grant
implementation
Update and strengthen guidance for CCMs and PRs on the selection and contracting of SRs to
increasingly ‘front load’ PR/SR selection and contracting processes prior to grant
implementation. Guidance should include
• Metrics which clearly define the time period within which SRs are expected to be selected
and contracted by PRs
• PRs to work with identified SRs to ensure roles, scope of activities and budgets are agreed
during grant making, ahead of the implementation period
• PRs should be strongly encouraged to effectively use Pre-Financing Policy flexibilities to
facilitate SR preparation (e.g. staff contracting, pre-financing some activities) in advance
of grant implementation
Consider embedding matching funds in the timeline for the design, approval and
implementation of the main grants to facilitate timely implementation of activities
Consider trying to better link financial and programmatic data by collecting data on the specific
outputs achieved through grant implementation, as well as collecting data at the sub-national
level, at least for some indicators
RECOMMENDATIONS:
Business Model
20. KEY FINDINGS:
Human rights
Activities to
reduce human
rights-related
barriers to
services are well
represented in
HIV grants, but
there is less focus
in TB and malaria
grants
Global Fund interventions to address human rights-related barriers in country grants
21. KEY FINDINGS:
Key and vulnerable populations (KVP)
• Investments by disease program largely cover key and vulnerable populations as defined by the
Global Fund but many country-defined KVPs do not align with the Global Fund definitions
Other HIV
• Fisher people: Uganda,
Senegal
• Bridge populations
(truckers, security forces,
traders, tourism): Senegal
• Pregnant women: Senegal
• Partners of PLWH:
Cambodia
• Partners of MSM:
Cambodia
• Partners of PWID:
Cambodia
• Clients of FEW: Cambodia
• Partners of sex workers:
Guatemala
• High risk individuals not
identifying as KVP:
Myanmar
Other TB
• People living with
diabetes: Cambodia,
Guatemala, Myanmar,
Senegal, Uganda
• People living in
overcrowded housing /
urban slums: Senegal,
Uganda
• Elderly people: Cambodia,
Myanmar
• TB contacts: Cambodia,
Uganda
• Students: Senegal
• Health care workers:
Myanmar
• Urban and rural poor:
Myanmar
Other Malaria
• Pregnant women:
Sudan, Uganda
• Children <5: Senegal,
Sudan, Uganda
• Forest workers,
dwellers: Cambodia,
Myanmar
• Seasonal workers:
Cambodia, Myanmar
• Military, border, armed
groups: Myanmar
• Camp/settlement
occupants: Myanmar
22. KEY FINDINGS:
Gender and Human Rights
Gender and human rights dimensions are not well understood or discussed
by stakeholders
• Perception that sex-specific targeting alone is sufficient for gender-
responsive programming
• Lack of experience among Ministry of Health and other stakeholders on
gender and on programs to reduce human rights-related barriers to
services (including legal dimensions)
• Few examples of programs that are actually addressing gender-related
vulnerabilities (DRC SASA! pilot project is an exception)
TB and malaria activities are less gender responsive
For example, despite greater TB prevalence in men, most programs
lacked interventions that addressed men’s gender-related risks
Overall implementation delays due to sub-contracting issues
23. RECOMMENDATIONS:
Human Rights, key and vulnerable populations, gender
The Global Fund Secretariat should
Ensure that Global Fund-supported programs clearly defines key and vulnerable
populations, aligned with national epidemiological context and that programs are
designed to allow for tracking of progress against key intervention areas (e.g.
disaggregation of male/female/trans sex workers, youth, women who inject drugs)
Continue efforts to build in-country capacity and expertise on gender and human-rights
related issues, e.g.:
• Developing clearer and more accessible guidance on human rights and gender programming
and implementation (already underway by Secretariat/CRG);
• Ensuring TA is consistent with country needs and facilitating countries seeking technical
assistance for reducing gender- and human rights-related barriers (e.g. help the CCM to know
that the mechanism exists and see the value in accessing TA to enable stronger more gender
responsive planning, implementation, and monitoring)
Country Stakeholders should
More explicitly articulate the gender-related vulnerabilities of men/boys, women/girls,
transgender and gender non-conforming individuals, the impact of these on disease-
specific outcomes, and specific strategies to mitigate these effects in funding requests and
designing disease-specific strategies.
24. RECOMMENDATIONS:
Human Rights, key and vulnerable populations, gender
The Global Fund Secretariat and Country Stakeholders should
Encourage more explicit promotion of gender and human rights integration throughout
the grant lifecycle, particularly for TB and malaria, including:
• Determine the appropriate mechanisms for ensuring the that high quality gender assessments
are conducted (or integrated into other assessment practices); e.g. further direct engagement
by Global Fund technical staff in specific country gender assessments
• Ensure each CCM has a qualified gender expert engaged throughout the grant design and
implementation process with the requirement that the gender expert is fully represented in all
processes and decisions
• Expand the requirements for addressing gender in funding requests and reporting, using clear
guidance that is understandable for both country teams and reviewers
• Programming and grant design (e.g. to address social norms, stigma, time use, and intra-
household decision-making, not just sex-based targeting)
• Implementation (e.g. collection and analysis of programmatic data disaggregated by key
populations)
26. KEY FINDINGS:
RSSH
Absorption across RSSH modules during Q1-Q2
2018 was low, in part due to the factors hindering
implementation more generally
Delays in RSSH implementation are due to similar
factors hindering overall grant implementation,
such as SR selection and contracting,
administrative / logistical hurdles, timing of
disbursements, staff turnover, etc.
Absorption by RSSH module, by country, across grants with RSSH investments, Q1-Q2 2018
27. KEY FINDINGS:
RSSH
RSSH coverage indicators predominantly align
with HMIS/M&E module, missing an opportunity
for monitoring other RSSH priorities
Despite limited early absorption, most grants
achieved 90+% on RSSH indicators
Achievement progress on RSSH HMIS indicators, by PCE country, by grant, Q1-Q2 2018
28. KEY FINDINGS:
RSSH
Many RSSH investments are considered shorter-term gap investments rather than longer-
term investments in more sustainable health system strengthening needs
Cambodia: RSSH investments are mainly
targeting “fixable” and “shorter term” issues
and lacking strategic focus, rather than
tackling systemic “longer term” challenges
facing the country, such as human resource
capacity
Uganda: Many direct RSSH investments
target the malaria program with limited
integration efforts (e.g. HRH investments
support national malaria control program
staff; community response investments to
improve malaria component of district
epidemic response system)
Myanmar: the HRH investment is largely
spent supporting seconded staff on project
coordination and logistics related to Global
Fund grants, which does little to address the
major health workforce shortages facing the
country
Sudan: the scattered approach to compiling
RSSH activities to fill gaps in short-term
disease-specific work plans is thought to have
resulted in limited investment in community
systems. Stakeholders note this as a missed
opportunity for Global Fund contributions to
Sudan’s intended national policy shift toward
health promotion and primary care
29. RECOMMENDATIONS:
RSSH
During the funding request development, consider mechanisms to incentivize
stronger alignment of crosscutting RSSH investments to longer-term national
strategies for health system strengthening, rather than addressing short-term,
disease-specific health system gaps
Improve standardization for categorization of RSSH investments within grant
budgets to ensure accurate quantification of Global Fund contributions toward
RSSH, including whether simplification is feasible or increased guidance and
examples are necessary
Improve monitoring and measurement of the outcomes of RSSH investments, e.g.:
• Clear articulation of expected RSSH outcomes, which can be translated into investment
guidance, the modular framework and grant performance framework where relevant;
• Stronger alignment of grant activities to indicators; and
• Consideration (and development of) community systems and responses indicator(s) in
the modular framework
The Global Fund Secretariat should
31. KEY FINDINGS:
Sustainability, Transition, Co-financing
All governments of PCE countries have made commitments to meet or exceed Global
Fund co-financing requirements
However, external stakeholders (e.g. CSOs, advocates, and evaluators) have been
unable to verify fulfillment in a timely manner in most countries
• Countries report to the Global Fund on their co-financing and realization of
specific commitments periodically, with assurance on country reporting through
a variety of country-specific mechanisms
• Reporting structures for domestic financing vary between countries, including
whether they are accessible to stakeholders
• National Health Accounts are one of the primary mechanisms for tracking
domestic financing and fulfillment of co-financing commitments, but most
mechanisms are retrospective in nature
32. KEY FINDINGS:
Sustainability, Transition, Co-financing
Even when countries do
meet co-financing
requirements, PCE
countries remain heavily
reliant on donor resources
to finance the disease
program
• This may pose a threat
to transition readiness,
programmatic and
financial sustainability
• Budget shortfall varies
by disease, with HIV
typically coming closer
to total needs costing
than TB
• Guatemala is an
exception
TB 2018-20
Funding Landscape
33. KEY FINDINGS:
Sustainability, Transition, Co-financing
There is evidence of countries embedding sustainability and transition considerations into
program design and implementation
Long-term sustainability planning
• Sustainability and transition
considerations were integrated
into grant design and national
strategic plans in Cambodia,
Myanmar, Guatemala, and Senegal
• Uganda finalized health financing
strategy, included a Social Health
Protection system and strategic
pooling of finances to strengthen
purchasing mechanisms
• The HIV NSP in Senegal has
prioritized the mobilization of
domestic resources to sustain the
national HIV response
Preparation for transition
• Guatemala has embedded a
sustainability and transition plan
into the TB NSP and is developing
a sustainability plan annex to the
HIV NSP
• A transition readiness assessment
in Cambodia found that funding
shortfalls in prevention would lead
to an increase in HIV incidence
and compromise the sustainability
of the HIV response
34. RECOMMENDATIONS:
Sustainability, Transition, Co-financing
Consider restructuring the country co-financing requirement to more
ambitiously increase domestic expenditure on health and the three diseases, with a
view to ensuring that domestic financing increases to a level that more fully
supports transition and sustainability objectives. Specifically, this might involve:
• Expanding upon the co-financing requirement to better reflect the
government’s existing financial commitments overall and within the wider health
financing landscape (e.g. by setting the co-financing requirement based on more
parameters than just the current two)
• Increasing the minimum level of co-financing that is acceptable to the Global
Fund (i.e. increasing the co-financing requirement but not necessarily the co-
financing incentive)
• Strengthening the incentive for countries to increase domestic expenditure on
health and the three diseases by making additional resources available to
countries that invest above the minimum acceptable level of co-financing (via a
separate mechanism than the existing incentive, which can only be taken away)
The Global Fund Secretariat should
36. KEY FINDINGS:
Value for money: Economy
Analysis of PQR data
suggests that economy
has improved over time
across the grants, with
health commodity prices
falling, often below
global reference prices
Some unit costs used for
budgeting do not closely
reflect actual costs,
potentially leading to:
• Global Fund paying
above the lowest
possible cost for
inputs; and or
• Low budget
absorption
37. KEY FINDINGS:
Value for money: Efficiency & Effectiveness
Strong examples of efforts to
improve efficiency of grant design
and national programs, particularly
in countries facing significant
reductions in program budgets
Program management costs vary
significantly across countries and by
type of PR, with substantially higher
costs for UN agencies and CSOs than
for governments
Cost-effectiveness considerations
inform program design and decision
making in most settings (such as
through modelling) but not
systematically
25%
7%
2%
24%
15%
12%
25%
33%
0%
10%
20%
30%
40%
50%
60%
0
100
200
300
400
500
600
DRC
(LIC)
Mozambique
(LIC)
Uganda
(LIC)
Myanmar
(Lower LMIC)
Sudan
(Lower LMIC)
Senegal
(LIC)
Cambodia
(Lower LMIC)
Guatemala
(Upper LMIC)
Programmanagementas%oftotalgrantbudget
Grantbudgets(USDmillions)
Program management budget Total grant budget Program management as % of grant amount
38. KEY FINDINGS:
Value for money: Equity
While equity is often discussed, trade-offs between equity, cost-effectiveness and
programmatic targets are dealt with differently (often informally)
More could be done to ensure that Global Fund-supported activities (and their
benefits) are fairly distributed amongst target recipients, e.g.:
• A review of the gender-related dimensions of equitable access to services and
reduction of vulnerabilities for men, women, boys, girls, and transgender
individuals
Some evidence that over ambitious target setting vis-à-vis available funding has been
counterproductive to the prioritization of hard-to-reach areas
Despite some examples of Global Fund support being used to reduce financial barriers
to accessing services, this still poses a significant issue
39. RECOMMENDATIONS:
Value for money
The Global Fund Secretariat, together with partners, should
Expedite work to collect unit/service delivery costs at the country level
and use this as a basis for budgeting, with clear guidance on appropriate
formulae to inflate estimates to allow for inflation, price changes, currency
shifts, etc.
Consider ways to strengthen country-level and/or grant-specific analysis of
VfM throughout the grant life-cycle (while considering the burden of
reporting), such as by:
• Collecting and analysing grant-specific output data
• Extending reporting tools to collect sub-national data
• Creating performance targets that better address equity
considerations
• Requesting that PRs/countries report against trends in efficiency and
effectiveness
41. PCE analysis provides in-depth
knowledge of the complexities of grant
implementation unlikely to be found in
thematic reviews/short country visits
PCE evidence is informing and/or
validating findings from TERG Thematic
and Strategic Reviews (e.g. RSSH and
Partnerships) and is able to use other
TERG Review findings prospectively
PCE is able to respond to emerging TERG
or Secretariat issues (e.g. business model
issues, CRG needs) and rapid requests
e.g. feasibility of implementing new MDR-
TB treatment guidelines (see example in
next slide)
PCE synthesis represents a whole that is
greater than the sum of the parts with
recommendations derived from and
consistent with the evidence from
multiple countries
PCE findings on lessons learned for key
processes (e.g. funding request
development, SR selection, etc.) will
inform Secretariat planning of the next
implementation cycle
Added value of the PCE: Global level
42. The PCE platforms in Myanmar, Sudan and
Uganda were mobilized at short notice by the
TERG to facilitate a preliminary review of the
feasibility and bottlenecks for transitioning to and
implementing the new guidelines (Dec 2018
start -Jan 2019 end)
High levels of trust between PCE team and
country stakeholders enabled access to key
informants, documents and data and this
contributed to the review’s success
The PCE review’s findings have provided a
baseline for the PCEs to follow up
prospectively in Myanmar, Uganda and Sudan
The PCE review provided country
recommendations for programmatic course
correction and Global Fund recommendations
for the current and next grant cycle
The PCE platforms are developing capacity and
agility to respond to emerging issues and have
the potential to be further development and
utilized. Discussions are underway for further
TB-related findings to be generated through
PCE in this way
Added Value of the PCE
Conducting a rapid review on the feasibility of
implementing new treatment guidelines for
MDR/RR-TB and LTBI in three PCE countries
43. Added value of the PCE: Country level
Targeting PCE findings to national
program managers: The ability to
disseminate emerging findings in a
timely manner is a core strength of
prospective evaluations and provides an
opportunity for the PCE to contribute to
continuous quality improvement
Opportunities for subnational data
collection and analysis can add value to
national level perspectives
Country stakeholders’ appreciation for
documenting the challenges, successes,
and learnings throughout the Global
Fund grant cycle – some of which are
previously known, but not
systematically or independently
documented, nor synthesized across
countries
Synthesis adds value at country level,
enabling stakeholders to compare their
responses to those of other countries as
well as understanding how the PCE is
part of a larger strategic process
44. What have we learned from the PCE approach?
Platform/Methods
• Results chain is helpful
analytic tool
• PCE knowledge of Global
Fund takes time to develop
but now seeing capacity &
agility to respond to
emerging issues
• Balancing competing
priorities and multiple
stakeholders is challenging
• Difficulty with timely
feedback when evaluating
processes that happen
once during the grant cycle
– findings relevant in 3
years
PCE Team Structure
• Strong linkages between
global and country
evaluation partners is
essential
• Various staffing models
among GEP and CEP – but
tracking 3 diseases
requires sufficient people
for embedded evaluation
model
• Opportunities for cross
GEP/CEP learning: in-
person, webinars, TERG
meetings
• Relationship building with
country stakeholders is
critical
PCE Reporting/Dissemination
• Dissemination needs to
be aligned with critical
data use periods
• Annual report
deliverable may be
inconsistent with
stakeholder preferences;
shorter, more frequent
briefs likely to be better
• PCE teams lack
knowledge translation
expertise – this could
help in dissemination
findings and
strengthening feedback
loop
PCE / TERG / Country Team Engagement
TERG meetings and presentations require significant time and input (high transaction costs)
Some inconsistencies in TERG feedback over time
CT engagement early and often is critical to ensure PCE is helpful to CT’s work
Stronger engagement with Global Fund Secretariat could help ensure added value and synergies,
while avoiding duplication
45. Process
Continued grant implementation monitoring and business
model process tracking
Greater use of root cause analysis to understand
implementation barriers and facilitators
“Deeper dive” inquiries into linkages between activities and
outcomes along the result chains to help explain observed
trends, using thematic areas as possible analytic lenses
Stronger emphasis on timely feedback to country
stakeholders and use of PCE findings
Plans for the PCE in 2019
46. Impact
Differentiated approach by country and disease
• Extend analysis of results chains
• Additional indicators and paths
• Country-specific tailored analysis
o Programs, populations or geographic regions of specific interest
to the country
Model-based impact analysis
• Statistical correlations between adjacent elements of results
chains (i.e. inputs vs. outputs; outputs vs. coverage, etc.)
• Structural equation modeling where complete data at sub-
national level are available
• Alternative (e.g. causal inference; epidemic) models where less
complete data are available
Plans for the PCE in 2019
Broad diversity of countries represented with grants of over $2.1b during the 2017-19 allocation
Mix of Upper LMI, Lower LMI, and LI
Mix of high impact and core portfolios
2/8 are COE (DRC, Sudan)
2/8 are AGYW priority countries (Uganda, Mozambique)
5/8 eligible for matching funds (Mozambique, Myanmar, Uganda, DRC, Senegal)
4/8 participating in CCM evolution pilot (DRC, Guatemala, Mozambique, Uganda)
The Secretariat succeeded in approving ‘disbursement ready’ grants on time in almost cases (Nov 2017 – Dec 2017). Depicted in Milestones slide as ochre coloured blocks
The Secretariat was successful in the timely transfer of funds to PRs in most cases, closely aligned to the timing of grant approvals. Depicted in Milestone slide as dark red blocks.
Matching funds were approval and aligned with main grant approvals in Myanmar and Mozambique (although this was not the case for DRC and Uganda). Depicted in Milestone slide as light blue blocks
CT’s allowed for flexibilities: Pre-financing of commodities or some SR activities (Ug and DRC resp); rapid budget revisions (Ug); 3 month contract extensions and/or bridge funding (Guatemala, Senegal, DRC).
Strong role played by CTs in helping address country specific start up issues acknowledged in at least half of the PCE countries .
Most PCE countries spent the first 6 months starting up grants and closing previous grants – reported as time consuming in several countries (Sudan, My, Uganda). In Sudan, old grants needed closing before ‘new’ continuation grants could start.
Transitioning PR-ship to national entities led to implementation delays in Senegal, Cambodia, Sudan (more bureaucracy, tighter risk measures, re-contracting of staff etc)
A major bottleneck in the majority of PCE countries was the selection, contracting and disbursement processes in-country (PR to SR). SR activities delayed due to relaunch selection process; lengthy PR/SR negotiations on role, scope of activities and budgets; size and complexity of grant implementation arrangements introduced e.g. in Sudan, 14 new SRs involved and subject to capacity assessments by new PR.
Misalignment of M Funds approvals which had knock on effect of delaying grant activities, particularly for SRs and their contracts linked to MF approvals (eg Uganda).
Note: selection and contracting of SRs is the area where GF guidance is least developed.
Trade offs:
PR transition: as GF increasingly shifts responsibilities to national programs/systems there may be trade offs on absorption, particularly during early implementation.
PR/SR contracting: GF promotion of country ownership by assigning responsibility of SR selection and contracting to PRs (under CCMs). Trade offs between ensuring quality SRs are selected, time required for contracting and knock on effects for grant planning, implementation and performance.
Source: Process tracking and document review in each country
Clustering of ochre blocks to depict on time signing of disbursement ready grants
Clustering of crimson blocks to depict timely first disbursement of funds (Secretariat to PR)
Clustering of light blue blocks in Dec 2017 to depict Matching Funds approved with main grants (and funds incorporated into those grants) in two of the four PCE countries. Matching Funds approved for Uganda and DRC at least 4 months later with disbursements following 2.5 months later.
SR contracting processes depicted by light grey bars indicating the duration of when multiple SR contracts were being signed. The darker grey is the duration of when 1st disbursements to multiple SRs were happening. The overlap in these durations is why there’s a third shade of medium grey (indicating the overlap).
Available financial data (which is only for January to June 2018) shows that budget absorption has been low
HIV expenditure in Q1 and Q2 of 2018 was only 14% of the original budget across the eight PCE countries, with some modules (e.g. prevention for transgender people and PSM) not beginning at all
Overall absorption of funds for malaria and TB grants was higher at 30% and 47%, respectively
Absorption for RSSH was very low at just 7%
[If not discussed above] The drivers of low absorption are numerous, including:
Delays in SR contracting and subsequent implementation
Grant architecture and grant management issues such as PR transition (Guatemala, Sudan, Cambodia, Senegal), SR selection/signing (DRC, Uganda, Senegal, Mozambique, Cambodia), variable Country Coordinating Mechanism (CCM) leadership (Guatemala, Mozambique), early budget revisions (Cambodia, Sudan, Uganda, Senegal), and burdensome administrative processes such as risk mitigation measures and grant closure processes (Mozambique, Myanmar, Uganda, Sudan).
Further, a number of country-specific contextual factors played important roles in early grant implementation progress e.g. the cash and fuel crisis in Sudan.
We do however understand that the absorption data looked worse than the situation in countries for two main reasons:
In practice, core services (e.g. treatment services provided by national programs) did not stop in between grants
Some expenditure that had been incurred was not reflected in the Global Fund collected data
While some activities were slow to get going, they are now underway and absorption is increasing dramatically.
Reflecting that the provision of core services did not stop between grants, early performance against grant coverage targets is mixed but generally high, with most countries achieving or nearly achieving targets on most performance indicators
Among HIV indicators, the median percent target achievement (i.e. the “achievement ratio”) was 79% across PCE countries
For TB it was 96%
For malaria it was 80%
The high achievement in relation to performance indicators is primarily because the indicators are focused on coverage, outcome and impact metrics that relate to the overall national program performance (rather than output metrics that can be attributed directly to grant performance, such as continuity in their contribution to the national program)
Of particular concern is the very low target achievement ratios for performance indicators focused on key populations, with a median achievement ratio of 15%. This may be partly explained by these performance indicators being some of the few that are focused on grant-specific outputs, where the implementation of activities is reliant on Global Fund funding.
There is no/limited correlation between:
financial reporting data, which shows that budget absorption is well below what was planned; and
programmatic data on performance, which suggests that grants are performing relatively well in most areas.
Note that this is short term budget absorption only. If low absorption sustained for longer it may begin to show a correlation
As such, financial reporting data and programmatic data on performance are often misaligned with short-term grant performance and implementation progress.
However, these form the basis for developing grant ratings, which influence Annual Funding Decisions and are reported to the Board. The lack of correlation between the two:
creates perverse incentives to implementers, by placing an over-emphasis on absorption, which encourages implementers to budget for activities that can be spent quickly and easily, possibly at the expense of activities that might have more impact; and
poses a risk to the Secretariat’s grant management function, and the Board’s governance function, at least in the short term
Work Plan Tracking Measures can be used to more accurately reflect short-term grant performance and implementation progress, but appear to be used inconsistently across countries.
In our view, and while we understand the sensitivity around this issue given the Global Fund’s previous decisions not to collect this data, some of these issues could be overcome by collecting data on the actual outputs achieved through the implementation of grant activities.
This would allow for better linkage of financial and programmatic data (i.e. on investments and results) and facilitate analysis of efficiency and effectiveness at the country level, which could inform programming
Analysis of data along the results chain at the sub-national level would also facilitate more comprehensive and systematic analysis of equity across the Global Fund portfolio, which could also inform programming. In the context of countries increasingly targeting interventions to increasingly concentrated epidemics, this sub-national analysis will become ever more important.
The Secretariat should consider trying to better link financial and programmatic data by collecting data on the specific outputs achieved through grant implementation, as well as collecting data at the sub-national level, at least for some indicators.
This has the potential to facilitate improvements to grant performance monitoring functions, such as through more comprehensive and systematic analysis of VfM across the Global Fund portfolio, as well as through the development of more nuanced grant performance ratings which inform annual funding decisions.
This finding raises questions around how best to promote more explicit gender and human rights integration into TB and malaria funding requests in the next cycle, where appropriate.
Global Fund and country definitions of key and vulnerable groups broadly align, but some inconsistencies exist
This raises questions around the appropriateness of the Global Fund’s KVP definitions, which have potential implications for investments for program targeting and coverage of KVPs (such as, is the Global Fund targeting the most appropriate KVPs for that country context, do we know the size of those populations, etc.?).
Gender and HR dimensions not well understood
Program managers see interventions targeting women (e.g., female drug users or malaria prevention for women and children) as gender responsive, but this kind of sex-specific targeting (while complementary) is distinct from gender-responsive programming which addresses gender-related vulnerabilities
Exception is DRC (SASA! pilot) where there is a real attempt to reduce vulnerability of adolescent girls and young women to GBV by working in the community, schools, and health centers to change harmful social norms – if implemented as designed/intended, which is not always the case.
In countries like Myanmar and Sudan, there was limited recognition of gender inequity in disease risk and burden
Absent a concrete focus on gender-related vulnerabilities, it may be difficult for Global Fund programming to have a significant impact on dismantling gender barriers
More detail on DRC SASA!
if done properly, SASA! falls into the category of gender-transformative approaches. The full SASA! approach is designed that way, and the “gender community” looks at it that way. There is a risk that SASA! “adaptations” in different countries fall short of the full approach (i.e. sometimes people put up some posters and have a few community dialogues and not much more, and say we’re doing SASA!) and it therefore end up as more gender-responsive than actually gender-transformative. Depends on how they’re doing it, and how well.
Sub-recipient contracting delays hindered the launch of key and vulnerable populations, human rights, and gender-related interventions in most countries. PRs often rely on SRs with community experience to deliver KVP, HR and gender interventions
In Cambodia, DRC, Mozambique, Senegal and Uganda, disbursements were delayed until Q2 or in some cases Q3 of 2018
Disagreement over implementation modalities and delayed arrival of matching funds
Lack of SR engagement during grant making was commonly cited across countries as a barrier, with many countries suggesting earlier SR involvement to ensure alignment on activities, targets, and budgets
Gender and human rights dimensions are not well-understood or discussed among stakeholders, causing delays in conceiving of, prioritizing and operationalizing initiatives.
Human rights initiatives that require understanding new content and forming new partnerships (e.g. with the legal community) may fall to a lower priority because of the time associated with building new relationships and understanding the key concept.
In many of the PCE countries, in part because of these delays, absorption was low in the first few quarters of 2018 for gender and human rights activities
Gender and human rights dimensions are not well-understood or discussed among stakeholders, causing delays in conceiving of, prioritizing and operationalizing initiatives.
Source: PUDRs Jan-Jun 2018
Myanmar’s relatively higher RSSH absorption is driven by the large proportion of the budget allocated to program management (salaries, transport, office costs).
Guatemala not included here due to grants being at a different stage of start up
PCEs will continue tracking implementation progress for RSSH activities in 2019, including whether absorption improves and if not, why not
Linkage to TERG RSSH Thematic Review:
CEPA: “Emphasis on absorption as performance metric creates perverse incentives for RSSH”
Source: PUDRs Jan-Jun 2018
Most grants with RSSH investments contain only one RSSH-related coverage indicator in the performance framework, usually related to either the timeliness or completeness of HMIS reporting.
PCE countries only included coverage indicators for HMIS and PSM (Senegal & Guatemala only).
The modular framework does not include RSSH indicators related to community systems or national health strategies.
There was a suggestion from one of the Secretariat reviewers to examine the Workplan Tracking Measures for RSSH – this is certainly an area we can cross check in the PCEs during 2019 to understand the extent to which RSSH interventions are being monitored by WPTMs… and whether those measures are appropriate/sufficient.
Finding consistent with TRP RSSH review and TERG RSSH Thematic Review:
TRP: Weak RSSH performance metrics and limited RSSH indicators
CEPA: Poor linkage between RSSH investments and outcome indicators in Modular Framework
The Uganda case highlighted some difficulty in applying guidance from the RSSH information note / investment framework document which states direct investments should be crosscutting in nature (with the exception of HMIS/M&E, all of which should be captured as “direct”)
Building on findings presented, we note challenges with both absorption and performance monitoring for RSSH investments. Absorption for RSSH investments was very low in most countries.
In addition to the reasons noted above, concerns about using RSSH funding for activities without clear performance metrics emerged, furthering challenges around misalignment of activities and performance.
TB Shortfall Larger than other diseases in percentage terms
Mean percentage gap for TB: 45%
Mean percentage gap for HIV: 30%
Mean percentage gap for malaria: 26%
The Global Fund Secretariat should consider restructuring the country co-financing requirement to more ambitiously increase domestic expenditure on health and the three diseases, with a view to ensuring that domestic financing increases to a level that more fully supports transition and sustainability objectives. Specifically, this might involve:
Expanding upon the co-financing requirement to better reflect the government’s existing financial commitments overall and within the wider health financing landscape. For instance, more explicit criteria related to government funding as a proportion of GDP, general government expenditure, total health expenditure and total disease program budget shortfalls, with the latter two including other donor contributions and private out-of-pocket (OOP) expenditures.
Increasing the minimum level of co-financing that is acceptable to the Global Fund. We understand that the Secretariat has been reluctant to do this as under the current incentive mechanism, the consequence of failing to meet the requirement is that an equivalent value would be withheld by the Global Fund from a future disbursement. This would place uncertainty over a significant proportion of the grant, which could jeopardise Strategic Objective 1. In our view, while this concern is valid, it could be avoided by restructuring the incentive mechanism to reduce the value of grant funds at stake for non-compliance. This would however serve to weaken the incentive mechanism somewhat.
Strengthening the incentive for countries to increase domestic expenditure on health and the three diseases beyond the minimum acceptable level of co-financing. The most striking mechanism to do this would be provide additional funding (i.e. over and above the budget allocation) to countries that exceed the minimum co-financing requirement (for instance by a certain percentage and ideally in a graduated manner). There are a number of potential ways that the Secretariat could do this:
Increasing the Global Fund budget allocation for high performing countries in the next grant cycle period.
Prioritising high performing countries for additional funding through their PAARs and/or catalytic funding, in particular, matching funds (which itself could be further targeted towards activities that promote sustainability objectives).
Such an approach might allow for greater dialogue between the Secretariat and country stakeholders on short-term domestic funding expectations, as well as longer-term objectives of the Global Fund related to transition and sustainability. We do however acknowledge the need for flexibility in the setting of co-financing requirements and incentives, such as in COE settings and particularly where there are strong arguments to suggest that increasing domestic funding for the three disease will come with a substantial/unacceptable opportunity cost (for instance with a proportional decrease in domestic funding for other health priorities The provision of matching funds already requires countries to commit an equal level of domestic resources to areas of strategic importance to the Global Fund.
Analysis of PQR data suggests that economy has improved over time across the grants, with health commodity prices falling, often below global reference prices.
Across the eight PCE countries, prices paid for ARVs, TB medications and antimalarial medications largely decreased over time. In many cases, prices were at or below the global reference price (mean and median) by 2018.
Around 65% of procured commodities are through the PPM, meaning that substantial volumes of commodities were procured outside of the Global Fund’s procurement systems.
The chart shows the prices paid for Abacavir (one of the most common ARVs purchased) have substantially declined over time to well below the global reference price in 2016 and 2017 across the 8 PCE countries, although there are some instances of countries purchasing at above the reference price. This is just one example, but similar declines were observed for other commodities across diseases.
There is evidence to suggest that the unit costs used as a basis for budgeting do not closely reflect the actual cost of inputs, posing a risk to both the economy and efficiency of Global Fund support.
The clear incentive for stakeholders is to ensure that sufficient resources are available to implement the planned activities, in order to avoid requesting additional resources from the Global Fund and to meet grant targets within the agreed resource envelope.
In Cambodia and Myanmar, the budgeted unit cost for inputs tend to be based on the estimates used for previous grant budgeting exercises, which are known to be inflated to allow for changes in prices and currency shifts and inflation, which can be significant when budgeting up to four years in advance.
This can lead to:
the Global Fund potentially paying above the lowest possible cost for inputs; and/or
low budget absorption, where inputs are purchased at a lower cost than budgeted, creating savings that then need to be reprogrammed. For instance, in Guatemala, commodities were over budgeted by up to 72%. Others were however under budgeted.
Whereas the quantity of inputs is scrutinized during grant making and linked to output targets, there is little evidence of input unit costs being subject to the same level of scrutiny.
This is partly due to a lack of data on unit costs and service delivery costs available at the country level.
The Global Fund’s support to the Global Health Costing Consortium (GHCC) seeks to address this issue by providing both a repository and reference prices for unit costs for HIV and TB interventions from published and grey literature. However, our review of this database suggests that cost estimates are only available in four out of eight PCE countries, three of which contained cost estimates for only 25 or fewer interventions, and many were extracted from studies more than 10 years old.
Examples of efforts to improve efficiency of grant design. Grant management arrangements have been changed in a number of countries, in part to reduce program management and administration costs. For instance in Cambodia where procurement arrangements were changed, and in Uganda where a standalone RSSH grant was embedded in disease grants.
Examples of efforts to improve efficiency of national program design. More targeted prevention services in Cambodia, Myanmar and Sudan; In DRC, bundled commodity distribution across programs is being implemented with positive expectations for efficiency, requiring fewer vehicles and human resources per shipment; Integration efforts across countries
Program management costs. The budget for program management as a proportion of the total grant budget varies from 2% in Uganda to 25% in DRC and Cambodia, with no clear link between a country’s stage along the development continuum and the program management budget. There is also no clear link between the size of grants and the proportion of the grant required for program management. Our analysis does show that program management costs are significantly higher for UN agencies and CSOs (which are mostly international and where costs are 26-27%) than for governments (where costs are 6%). In absolute terms, if the program management costs in Cambodia and Myanmar, where there are international PRs, could be brought down to a level equivalent for government PRs in other countries, this would result in a saving of around $30m.
Other points on efficiency:
Efficiency of grant implementation covered under business model
Initial analysis suggests that the efficiency of malaria programming is improving, with the cost per malaria case treated declining in DRC and Uganda over time. We intend to advance this sort of analysis, including explanations on what these trends represent and how and why they have occurred, in the year to come.
Cost-effectiveness considerations inform program design and decision making in most settings (such as through modeling) but not systematically
There is some evidence in all countries of grant interventions being targeted to correspond with burden of disease and address the specific needs of key populations, although how this allocation has been made has varied considerably, for instance with some countries not using the outputs of any analysis as the basis for programming, particularly for TB and malaria.
While equity is often discussed, trade-offs between equity, cost-effectiveness and programmatic targets are dealt with differently (often informally)
In Mozambique and Sudan, while cost-effectiveness considerations are taken into account, we understand that these can be superseded by political decisions on the allocation of resources between states and regions (such as for TB, for which resources and commodities are simply allocated equally between states), and not systematically used as the basis for decision-making.
More could be done to ensure that Global Fund-supported activities (and their benefits) are fairly distributed amongst target recipients
Our findings in relation to KVP, human rights and gender suggest that the Global Fund grants have not been designed to sufficiently address barriers/issues to ensure universal access to health and disease-specific services. Removing these barriers is critical to fairly distributing the benefits of Global Fund support amongst target recipients (i.e. to improve equity by ensuring that the benefits of activities are fairly distributed among target recipients.).
Our analysis of the correlation between Global Fund investments and the distribution of program interventions to burden of disease and KVP size estimates also supports the finding (although this does vary by country).
Some evidence that over ambitious target setting vis-à-vis available funding has been counterproductive to the prioritization of hard-to-reach areas
In Myanmar, there is some evidence that the Global Fund’s requirement to set ambitious targets (which stakeholders feel are overly ambitious) with a modest resource envelope meant that activities had to be focused in areas where TB burden is high, but also where the cost of service delivery is low. Because the Global Fund budget is insufficient to access all hard-to-reach areas (where the service delivery cost is high), prioritizing these areas would not allow for the achievement of Global Fund targets.
Relatedly, in Sudan, the reduced budget coupled with ambitious targets for HIV KVP services has led to the need to trial innovative service models that have not been trialled fully and have yet to demonstrate their effectiveness, which poses some degree of uncertainty that the approaches may not be effective enough to reach the targets.
Despite some examples of Global Fund support being used to reduce financial barriers to accessing services, this still poses a significant issue
There are high out-of-pocket payments for health care in all PCE countries, except for Mozambique.
Although this is lower for HIV, TB and malaria services than for other health services, these barriers can still be significant.
Evidence in Myanmar suggests that the Global Fund’s support for the living costs of TB patients has been a critical factor in reducing the (often significant) financial barriers associated with accessing TB services and is associated with Myanmar’s high MDR-TB treatment success rates as compared to regional and global levels.
In Uganda as well, over US$1.7 million has been allocated to socioeconomic approaches in their combined HIV/TB grant, the effects of which will be explored as implementation begins.
The Secretariat should expedite work to collect unit/service delivery costs at the country level and use this as a basis for budgeting, with clear guidance on appropriate formulae to inflate estimates to allow for inflation, price changes, currency shifts, etc.
The Secretariat should consider ways to strengthen country-level and/or grant-specific analysis of VfM (while seeking not to add to the burden of reporting), such as by:
Collecting and analysing grant-specific output data, at least for some indicators. This would ensure that reporting of programmatic data more closely reflects actual grant implementation performance (i.e. to strengthen the linkages between financial and programmatic data), and would enable some quantitative analysis of efficiency and effectiveness
Extending reporting tools to collect sub-national data; and creating performance targets that better address equity considerations. We expect both of these to become increasingly important as epidemics become increasingly concentrated, resources reduce and prevention activities are more and more targeted.
Requesting that PRs/countries report against quantitative trends for some indicators as proxies for efficiency and effectiveness, with qualitative explanations of what the trends represent, and how and why the observed trends occurred
Country examples for bullet 1:
DRC: PCE team shared timely findings from their data quality assessment with the Director and Data Manager of PNLP
Uganda: PCE team identified operational challenges during subnational data collection activities that were shared with national MOH officials and thereby promptly addressed
Synthesis point for bullet 4: found in Cambodia and Myanmar in 2017/18 at dissemination meeting
Added value in being present and different to LFA and OIG – these seems to have been important in Myanmar.