Professor Rifat Atun

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Clinic 1FCapacity Development Using Global Fund
grants to strengthen health systems
The Global Fund Partnership Forum Dakar, Senegal
8-10 December 2010

• Professor Rifat Atun
• Director, Strategy, Performance Evaluation
  Cluster

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Presentation Outline

• The Global Fund Health Systems Strengthening
• Community Systems Strengthening

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Global Fund commitment to HSS
Global Fund Board decision 2007 "The Global Fund
shall encourage applicants, wherever possible, to
integrate requests for funding for HSS actions
within the relevant disease component(s)." "Recog
nizing that some HSS actions (cross-cutting HSS
actions) may significantly benefit more than one
disease, the Global Fund shall allow applicants
to request funding for such HSS actions by
completing a distinct but complementary section
(a cross-cutting HSS section) within a disease
component"
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The Global Fund a major contributor to HSS

• 35 of 4Bn of approved financing is for key
  health systems elements
• Plus cross-cutting HSS funding
• 186Mn approved in R7
• 290Mn recommended by TRP in R8

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Use of Global Fund Grants for HSS (1)

• Direct funding of health systems elements
• Positive externalities of support provided to
  disease targeted programs
• Reducing the burden of major diseases
• gt ? workload productivity gains

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Use of Global Fund Grants for HSS (2)

• Expand governance capacity
• Community systems / civil society strengthening
• Public-private partnerships
• ME
• Financing
• Resource generation and allocation
• Human resources
• Targeting investments
• Enhance service delivery
• Structural improvements
• Supply chain management

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Use of Global Fund Grants for HSS (3)
Strengthening civil society and CBOs

• Expanding scope
• - Community systems strengthening
• PPM
• Increase social and gender equity (especially for
  women, girls and sexual minorities)

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Use of Global Fund Grants for HSS (4) Human
Resources

• Increasing the number of HR
• Salaries for health- and community-workers
• Salary top-up
• Incentives
• Training to develop and enhance capacity
• Enabling health workers to return to work
• Releasing HR capacity to address other health
  system priorities

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Use of Global Fund Grants for HSS (5)
Laboratory strengthening

• 67 of TB grants have included laboratory
  strengthening
• Examples
• Chad Newly equipped laboratories
• Philippines Service deliverers trained in sputum
  microscopy (public and private)
• Yemen New laboratories established for TB case
  detection

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Where HSS fits in logical framework
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The Context
Political
Epidemiological
Demographic
Governance
Equity
Health
Financing
Efficiency
Ecological
Financial Risk Protection
Legal
Resource generation allocation
Effectiveness
User Satisfaction
Service delivery
Responsiveness
Economic
Technological
Social
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Round 8 HSS summary (1)

• New cross-cutting HSS requests in one disease
• Submitted by 45 of 98 eligible applicants
• Amount requested 10 of overall R8 funding
  request over two years (10 of 5years, US1,268 m)

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Round 8 HSS summary (2)

• TRP recommendations with 45 'HSS requests'
• 17 instances both disease and HSS request
  supported
• 7 instances Only the disease 'part'
• 8 instances Only the 'HSS part' (for HIV
  tuberculosis)
• 13 instances Neither

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Round 8 HSS summary (3) areas of focus
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Round 8 HSS summary (4)budget categories
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Round 8 HSS summary (5) Critical success
factors in proposals

• Soundness of approach
• evidence-based interventions consistent with best
  practice,
• value for money,
• involve a broad range of stakeholders
• Feasibility
• technical programmatic feasibility of
  implementation,
• build on, complement and coordinate with existing
  (national) programs
• innovative approaches to scaling up programs
• Potential for sustainability and impact
• demonstrating that Global Fund financing will be
  additional
• addressing absorptive capacity issues,
• high-level sustained political involvement and
  commitment

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Round 8 HSS summary (6)

• WHO Building Blocks not optimal as 'operational
  framework' on which to prepare integrated
  responses to constraints, leading to 'formulaic'
  elaborations of HSS needs
• (Note Few requests in Financing
  Leadership/Governance)
• Community Systems Strengthening
• Most proposals included some level of CSS
  activity
• Covered the full range of activities
• However, not easily 'extracted' for
  analysis/proof of concept

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Best practice Ethiopia case study malaria with
HSS

• Addressed two national concerns
• Decentralisation Human resource shortage
• HSS Interventions
• Building community health systems HR
  strengthening through improved training capacity
  supervisor support
• Strengthening health information systems and ME
• Increase training institution capacity to support
  improved quality and output
• Comprehensive logistical support to ensure timely
  delivery of health services, medications and
  diagnostics

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Best practice Ethiopia case study

• Critical success factors
• Well described and focused HSS interventions
• Benefit all three diseases and beyond
• Budget and work plan clear
• Additionality to other donors demonstrated
• Integrated with national plan and system

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Round 8 HSS TRP Recommendations

• The TRP recommends to the Global Fund to
• Enlarge the 'space' available to elaborate HSS
  requests
• Consider how to ensure applicants assess their
  HSS needs in context of existing in-country
  reviews and Human Resources retention strategies
• Undertake a study of the stronger integrated
  examples
• Pursue a dialogue with WHO and other
  organizations (including academic, multi-lateral
  and bilateral organizations) to develop a more
  operational framework that applicants can use to
  identify integrated responses to HSS constraints
  in Global Fund (and GAVI) proposals.

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• The Global Fund Health Systems Strengthening
• Community Systems Strengthening

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Community systems strengthening

• Initiatives that contribute to the development
  and/or strengthening of community-based
  organizations (CBOs)
• To improve knowledge of, and access to, improved
  health service delivery
• Specifically to achieve improved outcomes for
  HIV, TB and malaria prevention, treatment, care
  and support programs
• Financial, technical and other kinds of support
  to CBOs

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Round 8 guidelines for CSS (March 2008)

• Capacity building of the core processes of CBOs
  through
• Physical infrastructure development
• Organizational systems development
• Systematic partnership building at the local
  level to
• Improve coordination
• Enhance impact
• Avoid duplication
• Build on one anothers skills and abilities
• Maximize service delivery coverage for the 3
  diseases and/or
• Sustainable financing
• create an environment for more predictable
  resources over a longer period of time

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Round 8 proposals CSS quantitative analysis

• All Round 8 Proposals Received
• 78 of the 230 Round 8 proposals received
  included CSS activities.
• Proposals from SEARO included CSS activities most
  often (95), followed by WPRO, AFRO and EMRO
  (80-90), and EURO and AMRO least often (65).
• Category 1, 2 or 2B Recommended Proposals
• 84 of the 108 proposals recommended for funding
  by the TRP as Category 1, 2 or 2B included CSS
  activities.
• Malaria and HIV proposals included CSS activities
  15-25 more often than Tuberculosis or section 4B
  HSS cross-cutting proposals.

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Round 8 Examples of CSS interventions

• Nigeria (HIV)
• strengthen capacity of core processes of
  community-based networks to ensure the provision
  of an increased range and quality of services in
  scaled up interventions for HIV, TB and malaria
• Sudan, Northern Sector (TB)
• development of community-based health insurance
  schemes
• Zimbabwe (Malaria)
• involve civil society and private sector in
  public health sector delivery
• Ethiopia (cross-cutting)
• task shifting policy to the community level
  HR strengthening of community- based staff
  through improved training capacity and supervisor
  support. NGOs involved in proposal development

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Common features of the Round 8 examples

• Promote longer-term approaches to capacity
  building, including organizational development
  and improved information management
• Clear strategy for ownership at the country
  level, and at local and community levels
• Ability to show that CSS support will be linked
  to improved service delivery and health outcomes,
  particularly for the three diseases

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Moving forward ..
From Results Report, 2008. The Global Fund to
Fight AIDS, TB and Malaria
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Addressing capacity development needs of CBOs

• Strategic planning
• Systematic review of organizational needs
• Funding assigned to strategic planning
• Funders feedback on proposals
• Management
• Funding assigned to management training
• Mentoring support
• Funding of mentoring partners
• Staff retention
• Salary/stipend harmonization
• Funding percentage assigned to carers

• Organizational efficiencies
• Medium to long-term vision and plans
• Organizational development plan
• More effective organizational management
• Strengthened administrative capacity
• Staff and volunteer capacity strengthened

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The health gap