Global Fund Prospective Country Evaluation

Global Fund

Prospective Country

Evaluation

2021 SYNTHESIS REPORT

19 February 2021

Myanmar

Knowledge

Management

CAMBODIA

DEMOCRATIC

REPUBLIC OF THE

CONGO

GUATEMALA

MOZAMBIQUE

MYANMAR

SENEGAL

SUDAN

UGANDA

DISCLAIMER

Views expressed in this report are those of the author. The author has been commissioned by

the Technical Evaluation Reference Group (TERG) of the Global Fund to Fight AIDS,

Tuberculosis and Malaria (the Global Fund) to conduct an assessment to provide input into

TERG’s recommendations or observations, where relevant and applicable, to the Global Fund.

This assessment does not necessarily reflect the views of the Global Fund or the TERG.

This report shall not be duplicated, used, or disclosed – in whole or in part without proper

attribution.

DISCLAIMER

Views expressed in this report are those of the author. The author has been commissioned by

the Technical Evaluation Reference Group (TERG) of the Global Fund to Fight AIDS,

Tuberculosis and Malaria (the Global Fund) to conduct an assessment to provide input into

TERG’s recommendations or observations, where relevant and applicable, to the Global Fund.

This assessment does not necessarily reflect the views of the Global Fund or the TERG.

This report shall not be duplicated, used, or disclosed – in whole or in part without proper

attribution.

DISCLAIMER

Views expressed in this report are those of the author. The author has been commissioned by

the Technical Evaluation Reference Group (TERG) of the Global Fund to Fight AIDS,

Tuberculosis and Malaria (the Global Fund) to conduct an assessment to provide input into

TERG’s recommendations or observations, where relevant and applicable, to the Global Fund.

This assessment does not necessarily reflect the views of the Global Fund or the TERG.

This report shall not be duplicated, used, or disclosed – in whole or in part without proper

attribution.

DISCLAIMER

Views expressed in this report are those of the author. The author has been commissioned by

the Technical Evaluation Reference Group (TERG) of the Global Fund to Fight AIDS,

Tuberculosis and Malaria (the Global Fund) to conduct an assessment to provide input into

TERG’s recommendations or observations, where relevant and applicable, to the Global Fund.

This assessment does not necessarily reflect the views of the Global Fund or the TERG.

This report shall not be duplicated, used, or disclosed – in whole or in part without proper

attribution.

DISCLAIMER

Views expressed in this report are those of the author. The author has been commissioned by

the Technical Evaluation Reference Group (TERG) of the Global Fund to Fight AIDS,

Tuberculosis and Malaria (the Global Fund) to conduct an assessment to provide input into

TERG’s recommendations or observations, where relevant and applicable, to the Global Fund.

This assessment does not necessarily reflect the views of the Global Fund or the TERG.

This report shall not be duplicated, used, or disclosed – in whole or in part without proper

attribution.

iii

Authorship

Alexander Marr

Allison Osterman

Audrey Batzel

Dr. Bernardo Hernandez Prado

Bethany Huntley

Casey Johanns

Christen Said

Emily Carnahan

Francisco Rios Casas

Dr. Herbert Duber

Dr. Juliann Moodley

Dr. Kate Macintyre

Dr. Katharine D. Shelley

Dr. Louisiana Lush

Matthew Cooper

Dr. Matthew Schneider

Dr. Nicole A. Salisbury

Patric Prado

Dr. Saira Nawaz

Thomas Glucksman

UCSF

PATH

IHME

UCSF

PATH

IHME

EHG

PATH

EHG

IHME

PATH

UCSF

PATH

IHME

 
 
iv 
 
Contents 
Authorship ................................................................................................................................................................................ iii 
Acronyms .................................................................................................................................................................................... v 
Executive Summary ............................................................................................................................................................ vii 
Chapter 1 .................................................................................................................................................................................... 1 
1.1 Introduction ................................................................................................................................................................. 1 
1.2 Grant cycle approach ............................................................................................................................................... 1 
1.3 Focus topics .................................................................................................................................................................. 2 
1.4 Methods .......................................................................................................................................................................... 3 
Data ..................................................................................................................................................................................... 3 
Budget variance ............................................................................................................................................................ 3 
Indicator performance tracking ............................................................................................................................ 4 
Root cause analyses .................................................................................................................................................... 4 
RSSH Support vs. Strengthening “2S” analysis .............................................................................................. 4 
Analytical approach to synthesis .......................................................................................................................... 4 
Chapter 2: NFM2 grant cycle ............................................................................................................................................ 5 
2.1: NFM2 funding request to grant making ........................................................................................................ 5 
2.2: NFM2 grant implementation .............................................................................................................................. 9 
Implementation Progress ........................................................................................................................................ 9 
The role of revisions during implementation .............................................................................................. 14 
Chapter 3: Lessons learned NFM2 to NFM3 ............................................................................................................ 22 
Chapter 4: Discussion and conclusions ..................................................................................................................... 35 
Chapter 5: Strategic recommendations/considerations ................................................................................... 36 
References ............................................................................................................................................................................... 39 
Annexes .........................................................................................................................................................................................I 
Annex 1. Summary of countries eligible for matching funds in NFM2 and NFM3 by type. .............I 
Annex 2. Qualitative data collected by PCE countries .......................................................................................I 
Annex  3.  Approach  to  identification  of  human  rights,  gender,  and  other  equity-related 
investments .......................................................................................................................................................................... II 
Annex 4. PCE 2020 Guidance on Operationalizing the 2S Framework ................................................... X 
Annex 5. Supplemental figures of budget changes by disease and RSSH ........................................ XVII 
Annex  6. Table  of cumulative absorption by year for all  modules, RSSH modules,  and  HRG-
Equity-related modules.............................................................................................................................................. XIX 
Annex 7: Application of the Global Fund’s performance-based funding model ............................. XXI 
 
   

Acronyms

ACT

Artemisinin-based combination therapy

APE

Agente Polivalente Elementars

AGYW

Adolescent girls and young women

ART

Antiretroviral therapy

C19RM

COVID-19 Response Mechanism

CCM

Country Coordinating Mechanism

CCS

Collaborating Centre for Health [Mozambique]

CEP

Country Evaluation Partner

CRG

Global Fund Communities, Rights, and Gender Team

COE

Challenging Operating Environment

CSO

Civil society organization

CSS

Community Systems strengthening

Country Team

DGS/DAGE

Direction Générale de la Santé/Direction de l’Administration Générale et de

l’Equipement [Sénégal]

DHIS2

District Health Information System 2

DRC

Democratic Republic of the Congo

EDT

Essential Data Tables

EHG

Euro Health Group

FEW

Female Entertainment Worker

FSW

Female sex worker

GAC

Grant Approvals Committee

GEP

Global Evaluation Partner

HMIS

Health Management Information System

HRG-Equity

Human rights, gender, equity

IHME

Institute for Health Metrics and Evaluation

ISD

Integrated service delivery

KII

Key informant interview

KVP

Key and vulnerable population

LFA

Local Fund Agent

LIC

Low-income country

LLIN

Long-lasting insecticide-treated net

LMIC

Lower-middle income country

M&E

Monitoring and evaluation

MDR-TB

Multidrug-resistant tuberculosis

MMT

Methadone maintenance treatment

MoH

Ministry of Health

MoHA

Ministry of Home Affairs [Myanmar]

MoU

Memorandum of Understanding

MSAS

Ministère de la Santé et des Affaires Sociales [Sénégal]

MSM

Men who have sex with men

NFM2

New Funding Model 2 (2017-2019 funding cycle)

NFM3

New Funding Model 3 (2020-2022 funding cycle)

NSP

National Strategic Plan

OBR

Official Budget Revision

OIG

Office of the Inspector General

OPN

Operational Policy Note

PAAR

Prioritized Above Allocation Request

PCE

Prospective Country Evaluation

PLHIV

People living with HIV

PMTCT

Prevention of mother-to-child transmission

Principal Recipient

PSM

Procurement and supply chain management

PU/DR

Progress update and disbursement request

PWID

People who inject drugs

Quality Assurance

RAI3E

Regional Artemisinin-resistance Initiative 2 Elimination Program

RCA

Root cause analysis

RSSH

Resilient and sustainable systems for health

Strategic Objective

Sub-recipient

STC

Sustainability, transition, and co-financing policy

TERG

Technical Evaluation Reference Group

TRP

Technical Review Panel

UCSF

University of California, San Francisco

UHC

Universal health coverage

UMIC

Upper middle income country

UNOPS

United Nations Office for Project Services

UQD

VfM

Value for Money

WPTM

Work Plan Tracking Measures

vii

Executive Summary

Introduction

In 2020, the Prospective Country Evaluation (PCE) took a comprehensive look at the Global Fund

grant cycle, assessing how business model factors have facilitated or hindered the achievement

of objectives during implementation of grants approved through New Funding Model 2 (NFM2;

2017-2019 funding cycle), including around Resilient and Sustainable Systems for Health (RSSH),

sustainability and equity, and whether lessons learned during the current grant have informed

the next funding cycle. In this report, we present our synthesis of findings from eight PCE

countries: Cambodia, DRC, Guatemala, Mozambique, Myanmar, Senegal, Sudan and Uganda. The

objective of the grant cycle analysis was to understand what, when, why and how grant

investments change over time, including significant factors that influenced the implementation of

and changes to the original grant. In each country, this was assessed using focus topics as lenses

to evaluate the grant cycle and to better understand drivers of change. This report follows the

grant cycle, first presenting synthesis findings from NFM2, including the funding request and

grant making process and implementation, followed by how the NFM3 (2020-2022 funding cycle)

grant design process was informed by lessons from NFM2. Conclusions related to grant design

and implementation are discussed in Chapter 4, focusing primarily on RSSH and human rights,

gender and other equity-related investments (HRG-Equity), paralleling Global Fund Strategic

Objectives 2 and 3.

NFM2 funding request to grant making

The PCE found that grant design and budgets did not change significantly during the NFM2 grant

making process from the Global Fund’s Technical Review Panel (TRP)-approved funding

requests, although proportionally more changes were made to investments in HRG-Equity and

RSSH areas. In the majority of PCE countries, investments in reducing HRG-Equity barriers

declined during grant making, whereas RSSH budgets show large increases in some countries and

declines in others. Factors that influenced prioritization and changes during grant making

included Country Team support and input, catalytic matching funds investments and TRP review

and comments, among others.

NFM2 grant implementation

NFM2 grant implementation has been uneven, including start-up delays during Year 1, primarily

as a result of the lengthy selection and contracting processes for sub-recipient implementers.

After grant start-up, absorption performance increased in Year 2, although weak grant

coordination and issues with performance monitoring constrained ongoing implementation

progress. The PCE found that early implementation delays disproportionately affected RSSH and

HRG-Equity activities and absorption remained particularly low in some RSSH and HRG-Equity-

related investment areas. However, regular progress reviews and grant coordination meetings

among key stakeholders helped accelerate implementation of the grants. During Year 3, the onset

of the COVID-19 pandemic caused significant disruption, particularly for HRG-Equity

investments, which required agile adaptations. Grant revision processes introduced to support

Building from this 2021 PCE Synthesis Report, the TERG commissioned a three-month extension phase

(April-June 2021) to focus on deeper analysis. Key areas explored included: NFM2 grant revision issues

and lessons learnt from the Global Fund’s response to COVID-19; Health systems support and

strengthening; Reasons for the limited uptake of RSSH coverage indicators; and NFM3 grant making,

including drivers of budgetary shifts and transparency, country ownership and inclusion. Additional

findings and recommendations are being produced.

viii

the COVID-19 response were flexible and a reasonably ‘light lift’ for country stakeholders,

enabling rapid implementation adjustments in 2020.

In contrast, grant revisions are usually perceived as burdensome and administratively complex.

Additional funding revisions tended to occur earlier in the grant lifecycle, initiated by the

Secretariat and negotiated between the Country Teams (CTs), Country Coordination Mechanisms

(CCMs) and grant recipients, and were based on reviews of high-priority activities from the

scope of grants were uncommon, occurring in only four PCE countries. Evidence from some PCE

countries suggests that some potential program revisions (e.g., where new evidence became

available) were not undertaken during NFM2 and were instead shifted for inclusion in NFM3

funding requests—in part due to the burdensome program revision process and the short three-

year implementation cycle. PCE countries most frequently made budget revisions (‘reallocation’)

as a financial management tool to influence absorption. In most PCE countries, this resulted in a

cumulative shifting of unused resources to later in the grant cycle, rather than undertaking a more

substantial program revision, particularly for low absorbing RSSH and HRG-Equity interventions.

Using budget revisions systematically to shift unutilized resources from Year 1 to Years 2 and 3,

and subsequently from Year 2 to Year 3, has significant potential to reduce allocative efficiency.

The lack of sufficient programmatic performance data upon which to guide revision decisions

likely contributes to the emphasis on using budget revisions to influence absorption.

The annual funding decision does not appear to be working as intended to operationalize the

principle of performance-based funding. Specifically, disbursements often varied dramatically

from the total agreed budget for each reporting period and, even when performance against grant

targets and indicators was weak, disbursements were often above or a relatively high proportion

of the total grant budget. As such, it is unclear if or how disbursements are being used to

incentivize performance.

Lessons learned NFM2 to NFM3

Ensuring grants are well designed at the time of the grant award is critical. In most PCE countries,

the NFM3 funding request process was an improvement over NFM2. With some variation, it was

more streamlined, efficient and flexible, characterized by improved country ownership,

participation by a wider group of stakeholders and with a range of business model factors used

effectively to influence grant priorities. However, despite greater inclusivity, transparency and

country ownership during funding request development, this tended to decline during the grant

making stage, where key decisions were often taken. Nonetheless, KVP representatives reported

feeling more included in NFM3 funding request processes than in NFM2, in some cases helped by

having gained experience from previous processes and having received support to build their

capacity. The efficiency of the Matching Funds application process also improved for NFM3

compared to NFM2. TRP recommendations (made both on NFM2 and NFM3 funding requests)

informed NFM3 grant designs, often with implications for HRG-Equity and RSSH related

investments. However, across all application approaches, COVID-19 changed the way the funding

request and grant making processes were managed, with both positive and negative implications.

The Global Fund’s successful Sixth Replenishment, alongside a commitment to ‘do things

differently’ offered an important opportunity to ‘change the trajectory’ in NFM3. NFM3 funding

requests included significantly larger budgets and focus on some—but not all—of the areas

where a change in trajectory is needed to meet the Global Fund Strategic Objectives.

HRG-Equity: PCE countries show evidence of NFM3 funding requests being designed with

explicitly more focus than in NFM2 on improving equitable access to health services and

allocating resources to intervention approaches that are known to contribute to greater

programmatic sustainability. However, in some cases, efficiency and/or effectiveness

considerations appear to have taken precedence over equity considerations in NFM3 grant

design. For instance, in response to concerns with efficiency, some countries adjusted NFM3 PR

and SR implementation arrangements with potentially negative consequences for equity. On the

other hand, several PCE countries used better-quality and/or more recent data on KVPs during

NFM3 compared to NFM2, which enabled grants to set up new interventions to target KVPs more

precisely or widen the geographical distribution of places that KVPs would receive services.

However, the quality of data (particularly the accuracy of KVP population size estimates)

continues to constrain these decisions and overall allocative efficiency.

RSSH: Most PCE countries increased their allocation to RSSH in NFM3, although, compared to

NFM2, a greater proportion of these investments are designed to support rather than strengthen

health systems. As such, it is unclear how the NFM3 grants are intended to ‘change the trajectory’

for the achievement of SO2. Evidence suggests that the Global Fund’s RSSH guidance “to shift from

a focus on short-term, input-focused support...towards more strategic investments...that build

capacity and lead to sustainable results”(1) is not being systematically operationalized. In some

countries, NFM3 RSSH investment design builds upon progress made during NFM2, especially in

HMIS/M&E, but most PCE grants did not appear to use the NFM3 funding request process to link

RSSH investments more strategically with sustainability plans. In some countries, NFM3 grants

are shifting RSSH intervention approaches, with greater emphasis on community systems

strengthening for improving access to and quality of service delivery. Several countries show

governance adaptations to improve coordination and implementation of crosscutting RSSH

investments. Despite extensive new guidance, most NFM3 grant performance frameworks do not

appear to include many of the new RSSH coverage indicators, suggesting that monitoring RSSH

performance and progress toward meeting SO2 will remain a challenge. Coverage indicators

rarely capture aspects of system strengthening (such as data use for decision-making) and some

RSSH investment areas do not map well to available indicators.

Conclusions

Grant design

1. Improvements to the business model between NFM2 and NFM3 contributed to more

efficient and inclusive funding request processes. However, NFM3 saw limited adoption

of changes in the design of performance monitoring, particularly for HRG-equity and

RSSH.

2. In NFM3, both RSSH and HRG-Equity investments rose, in many cases as a result of

overall allocation increases. An increased proportion of RSSH investment is directed

toward activities that support rather than strengthen the health system.

Grant implementation

3. Implementation of NFM2 grants faced significant start-up delays and COVID-19

interruptions. Absorption was overall weaker for RSSH and HRG-Equity interventions.

4. Multiple barriers and challenges exist for undertaking revisions to the scope and/or

scale of grants mid-cycle, such as in response to new evidence or emerging performance

issues.

Recommendations

Recommendation 1: Improve grant-specific performance monitoring to inform

implementation decisions.

• Establish routine grant review processes at the country level with a quality improvement

lens, emphasizing grant-specific performance data and drawing on emerging evidence

and data to better inform revisions that maximize impact. (PRs, Grant Management

Division including Country Teams)

• Implement proposed reforms of the grant rating system to reflect both grant-specific

performance and contribution of Global Fund grants to national program performance.

Additionally, this should draw upon qualitative inputs, including expertise of the CCM,

LFA, Country Team and wider Secretariat. (Grant Management Division, Strategy

Committee, Board)

• Based on the revised grant rating system, the Secretariat should also develop a set of

indicative options to demonstrate how good and poor performance could be responded

to, and a framework for deciding when and how to introduce these measures in different

contexts and circumstances (Grant Management Division, Strategy Committee, Board).

• Strengthen the use of revised RSSH indicators to address delayed implementation and

potential deprioritization throughout grant implementation. (PRs, Grant Management

Division including Country Teams)

Recommendation 2: Build in more flexibility and responsiveness in implementation by

simplifying grant revision processes to encourage their use throughout the grant cycle.

• Consider flexibilities and streamlining of material program revision process to

encourage/reward earlier introduction of innovative programming that maximizes

impact and limits non-strategic budgetary shifts to later in the 3-year grant cycle.

(Secretariat)

• Introduce flexibilities to PR and SR contractual arrangements and performance

frameworks that can be used to introduce mid-term changes as required. (PRs, Grant

Management Division)

• Through the Secretariat’s planned grant revision review (mid-2021), examine how

countries could strengthen data-driven revision decisions (thereby avoiding the over-

reliance on financial data to guide revision decisions), in line with establishing a more

streamlined, flexible process for program revision. (Secretariat)

Recommendation 3: In order to reduce gaps between policy guidance and grant design,

improve communication around how to invest more strategically in RSSH, including CSS.

• In the next Strategy, the Global Fund board in collaboration with the Secretariat should

clarify their position on whether the primary objective of RSSH is to support the three

disease programs or to invest more holistically in health systems strengthening. (Board,

Secretariat RSSH team)

• Clarify specific Global Fund RSSH priority areas and what strengthening as opposed to

supportive investment would look like for these, including specific purpose, indicators

and targets in performance frameworks. (Secretariat RSSH team, Country Teams)

• To facilitate integration and strengthening RSSH, ensure proper engagement and

ownership from health system planning experts and leaders to support health sector-

wide programming decisions, including alignment of grant design and sustainable

financing within wider national health, health system and UHC policy context, and the

timelines associated with broader strengthening efforts. (PRs, Country Teams)

Recommendation 4: In order to improve grant contribution to equity and SO3, explicitly

promote grant investments in these areas, including through more direct measurement

of the drivers of inequity and of outcomes of human rights and gender investments.

• Invest more in data and data use, including up-to-date KVP surveys as well as other data

sources that shed light on socio-economic, gender, geographical and ethnic differences in

disease burden and access to services that grants are aiming to contribute to. (Country

Teams, national stakeholders)

• Ensure performance frameworks incorporate existing data including on human rights

and political commitment as well as disease burden and service access amongst different

population groups and use this data effectively to monitor grant contribution to both SO3

and SO1 or disease impact. (Country Teams, national stakeholders)

• Recognizing the success of strategic initiatives and/or matching funds in incentivizing

grant investments in reducing equity, human rights and gender related barriers to

accessing services, prioritize scaling up across the portfolio and incentivizing such

investments through mainstream grant management operations. This should include

explicit efforts to improve implementation and where necessary, timely revisions to

maximize grant contribution to reducing barriers to care and disease impact. (Grant

Management Division, Strategic Initiatives team)

Chapter 1

1.1 Introduction

The Prospective Country Evaluation (PCE) is an independent, multi-year prospective evaluation

of the Global Fund, commissioned by the Global Fund’s Technical Evaluation Reference Group

(TERG). The goal of the PCE is to evaluate how the Global Fund business model operates in eight

countries in order to generate evidence that will accelerate progress towards meeting the Global

Fund Strategic Objectives (SOs). The PCE is led by two Global Evaluation Partners (GEPs), in

collaboration with eight Country Evaluation Partners (CEPs). The Euro Health Group/University

of California San Francisco (EHG/UCSF) consortium supports Cambodia, Mozambique, Myanmar

and Sudan; the Institute for Health Metrics and Evaluation (IHME)/PATH consortium supports

the Democratic Republic of the Congo (DRC), Guatemala, Senegal and Uganda. These eight

countries, although not selected to be formally representative of the Global Fund portfolio overall,

comprise approximately 20% of the investment during the 2017-2019 allocation period (US$2.2

billion) and 2020-2022 allocation period (US$2.5 billion), and present an array of disease

epidemics, geographies, development statuses and Global Fund support (Table 1, with additional

details available in Annex 1). Among the countries, only Guatemala is transition-eligible for

malaria and TB in the next funding cycle.

Table 1. PCE Portfolio Characteristics (US$)

Characteristic

CAM

DRC

GTM

MOZ

MYN

SEN

SDN

UGA

Total

World Bank Income Group

LMIC

LIC

UMIC

LIC

LMIC

LIC

High Impact Portfolio

Core Portfolio

Challenging Operating Environment (COE)

AGYW Priority Country

Matching funds eligible (NFM2, millions)

$16.0

$19.7

$19.3

$2.5

$9.4

$66.9

Matching funds eligible (NFM3, millions)(2)

$6.0

$12.6

$22.4

$12.3

$1.3

$23.5

$77.9

Table Notes: LIC = low income country; LMIC = lower-middle income country, UMIC = upper middle income country

1.2 Grant cycle approach

Each year, the PCE synthesizes country findings to present a more comprehensive assessment of

the Global Fund business model. During the 2020 evaluation phase, the approach was informed

by the TERG’s interest in understanding how the Global Fund grant cycle has facilitated or

hindered the achievement of grant objectives during implementation within the New Funding

Model 2 (NFM2) grant cycle (2017-2019 funding cycle), including around Resilient and

sustainable systems for health (RSSH), sustainability and equity, and whether lessons learned

during the current grants have informed the New Funding Model 3 (NFM3) (2020-2022 funding

cycle). Applying a mixed-methods approach, information was collected from a variety of

quantitative and qualitative data sources; through analysis and data triangulation, the PCE

generated results that elucidate how the Global Fund business model plays out in-country.

The objective of the grant cycle analysis was to understand what, when, why and how grant

investments change over time, including significant factors that influenced the implementation of

and changes to the original grant. We examined aspects of grant design and implementation, and

specifically aimed to evaluate:

● how and why the NFM2 grants were modified along the grant cycle (during grant making,

implementation, and grant revision);

● how the Global Fund business model facilitated or hindered modifications along the grant

cycle; and

● whether and how grants contributed to achieving progress towards (or away from)

equity, sustainability and/or health systems strengthening objectives.

In addition, the PCE assessed the 2020 funding request and grant making process for NFM3 on

five themes, relative to the NFM2 process where relevant: (1) Differentiated applications: tailored

review, program continuation, and full review; (2) Transparency, inclusion, and country

ownership; (3) Moving beyond ‘business as usual’ to change in trajectory for achieving impact;

(4) Data use and target setting; and (5) Value for money.

The PCE used a Grant Cycle framework (Figure 1) as the primary evaluation framework for

organizing 2020 data collection and analysis. The Global Fund grant cycle begins with the funding

request development leading to grant making, grant award, and grant signing. This process takes

eight to nine months and is followed by a three-year implementation period during which funds

are disbursed, activities are implemented, grants are modified through revision processes, and

progress is monitored. During the third and final year of implementation, the next funding

request development and grant making process begins for the upcoming grants and aims to be

informed by lessons learned from the current grants.

Figure 1. Grant cycle framework

NFM2 grant design: Little is known

about shifts between the Technical

Review Panel (TRP)-reviewed

funding request and grant making.

We examine shifts during the grant

making process as they relate to

Global Fund strategic objectives,

including prioritization of equity and

RSSH in funding requests and shifts in

equity and RSSH-related investments

during grant making.

NFM2 implementation: We examine

performance against grant and

national program indicators and

targets, Global Fund strategic

objectives, and implementation

progress, including the barriers and

facilitators to implementing RSSH

and equity-related investments. We

further examine budgetary shifts and

the role of grant revisions in

enhancing or detracting from RSSH

and equity investments.

NFM2 vs. NFM3: Global Fund’s 2019 replenishment set commitments to change the trajectory to meet

2030 disease goals. We compare NFM2 and NFM3 investments and interventions, exploring whether

lessons learned in NFM2 are informing the NFM3 funding request processes and grant design, with a

particular focus on equity, RSSH, and sustainability.

1.3 Focus topics

The PCE used a series of focus topics as lenses through which to evaluate the grant cycle and to

better understand drivers of change and results at the country level (figure 2). Focus topics were

selected with relevance to equity, RSSH and, in limited instances, sustainability considerations.

Through these focus areas, we examined how and why grants were modified along the grant cycle,

successes and bottlenecks to implementation, and results achievement against grant

performance targets.

Figure 2. Focus topics by country and theme

1.4 Methods

The PCE employed a mixed methods approach to assess how Global Fund business model factors

influence performance of grants throughout the stages of the grant cycle. Relying upon analyses

using both quantitative and qualitative data, the PCE examined and sought to explain changes in

planned resources and activities throughout the grant making process, revisions and

performance during grant implementation, as well as changes to the next grant window.

Triangulation of data across multiple sources and analytic approaches was used to ensure

robustness of findings, and interpretation of findings was commonly based on more than one

analysis. The EHG/UCSF consortium used contribution analysis to structure the interpretation of

findings against evaluation questions focused around the contribution of grant inputs (resources

and other inputs) to national disease program outcomes, as well as to assess the degree to which

this also enabled the achievement of Global Fund Strategic Objectives.

Data

Primary data were collected through meeting observations and key informant interviews (KIIs)

to explore issues in-depth; in addition, fact-checking interviews were conducted to fill

information gaps (Annex 2). KIIs elicited stakeholder perspectives on global and country-specific

evaluation questions and allowed the PCE to better understand grant cycle processes, including

barriers and facilitators. Interviews were also used to triangulate, interpret and validate results

generated through quantitative analyses and document review. Interview transcripts and

meeting notes were coded according to key themes.

The PCE obtained detailed budgets for all available active and planned grants from the Global

Fund Secretariat for funding requests, approved grants, awarded for grant making, and official

revisions (with corresponding Implementation Letters). In addition to detailed budgets, local

fund agent (LFA)-verified progress update/disbursement requests (PU/DRs) were obtained.

Budget variance

The PCE conducted detailed financial analyses of Global Fund budgets throughout the grant cycle

for NFM2 grants as well as available budgets from funding requests to grant making during NFM3.

Budgets were analyzed by recipient, disease, module, intervention, and focus topic.

Observed

changes in financial resources and prioritization between activities were triangulated using

qualitative data collected during KIIs, document review, and additional interviews. Using the

Global Fund’s modular framework, the PCE tracked resources for RSSH and human rights, gender,

and other equity (HRG-Equity) related interventions. HRG-Equity modules and interventions

were identified using Global Fund’s disease-specific technical briefs on gender, human rights, and

key populations; gender technical briefs; and validated through conversations with the Global

Fund Secretariat’s Community, Rights and Gender (CRG) team. Additional details can be found in

Annex 3, including a complete table of modules and interventions included in the PCE analysis of

HRG-Equity.

An analysis of financial absorption (expenditure as a percentage of budget) within and across

grants was conducted using PU/DRs, examining trends in absorption by semester, module, and

intervention. Similarly, absorption for RSSH- and HRG-Equity-related modules and interventions

were tracked throughout the grant cycle.

Indicator performance tracking

Indicator achievement against targets are reported within the LFA-verified PU/DRs during grant

implementation. These data were also compiled and tracked over the grant cycle to understand

changes in performance across grants, focus topics, and RSSH and HRG-Equity. Insights from

indicator trends over time were used to guide KIIs and fact checking interviews to triangulate

how the Global Fund business model facilitated or hindered performance.

Root cause analyses

The PCE used root cause analyses (RCA) to further explore, analyze and understand the root

causes underlying observed challenges or successes identified through a variety of triangulated

data sources (KIIs, secondary data analysis, document review).

RSSH Support vs. Strengthening “2S” analysis

The PCE analyzed RSSH activities in NFM2 and NFM3 according to whether they contributed to

“systems support” or “system strengthening,” drawing on definitions from Chee et al. (2013). (3)

We developed a coding methodology, aligned to Global Fund’s RSSH modules in the modular

framework, to designate each RSSH activity in the budget as either predominantly support or

strengthening. Three parameters—scope, longevity, and approach—were examined for each

RSSH intervention/activity pair, adapted from the methodology previously used by the TRP’s

examination of RSSH in the 2017-2019 funding cycle.(4) Two coders independently applied a

determination of support or strengthening after reviewing each intervention and activity

description, and any relevant text in the funding request narrative, and cost category. Details on

the methodology used are available in Annex 3.

Analytical approach to synthesis

Drawing from country analyses and annual reports, the GEPs compiled quantitative and

qualitative evidence into matrices organized by grant cycle stage and RSSH, equity, and

sustainability thematic areas. Evidence was drawn from focus topics as well as grant- and

country-level analyses. The evidence matrices helped identify patterns in the data across

countries and informed further discussion and analytical triangulation with cross-country budget

variance data. Due to the variation of focus topics, not all findings were able to be substantiated

across the eight countries; wherever possible, findings were supported by additional country

focus topics and portfolio-level analyses. Early synthesis findings were validated with CEP teams

for feedback and additional data interpretation.

Some budgets were not included in the synthesis as these grants were not subject to analysis at the country level

during the course of 2019-20, namely: Sudan HIV/TB, Cambodia malaria, and Myanmar malaria.

Chapter 2: NFM2 grant cycle

2.1: NFM2 funding request to grant making

This section presents findings on the changes that were made during 2017/2018 to NFM2 grant

designs between the country funding request submissions and the final approved grant award—

i.e., through the grant making process. This includes analysis of how and why changes were made,

who suggested that they be made, and whether these changes were in line with the Global Fund

guiding policies and priorities.

Key message 1: Overall grant designs and budgets did not change significantly during the

2017 grant making process (NFM2). More substantial changes were made to investments

supporting the achievement of SO2 (RSSH) and SO3 (HRG), although not necessarily to

prioritize these areas (despite being consistently highlighted through the PCE and other

analyses as requiring more attention).

In general, during NFM2, relatively few major changes in overall grant design and budgets

occurred between funding requests and final approved grant awards for PCE countries (as seen

in Annex 5 figures 5.1, 5.2 and 5.3). Proportionally (given investments in these areas are relatively

small compared to the overall grants), more significant changes were made to investments in

HRG-Equity and RSSH for most PCE countries during the NFM2 grant making process (Figure 3).

Figure 3. Percent change in RSSH (left) and HRG-Equity (right) investments from NFM2 funding

request to grant award

Source: Global Fund detailed budgets

HRG-Equity Investments

Analysis of all investments that seek to address HRG-Equity-related barriers to access and/or

health outcomes show that the budget for these areas declined in six of the eight PCE countries

during the grant making process. While no clear patterns emerged for TB and malaria (for which

these types of investments are small and difficult to track), HIV grant budgets mostly declined,

particularly for prevention among key and vulnerable populations (KVPs). Specifically, in all

countries that included some budget allocation for the following modules, the budget decreased

between the funding request and grant award:

● Prevention for Men who have sex with men (MSM): Substantial declines in

Mozambique, DRC and Guatemala.

● Prevention for People who inject drugs (PWID): Almost complete removal in

Mozambique and heavy cuts in DRC.

To ensure comparability, we restricted the grants to only those with full and tailored review (excludes continuation

grants for malaria in DRC, Mozambique, Senegal and Sudan, as well as HIV in Senegal and Sudan, and TB in Sudan).

● Prevention among prisoners: Complete removal in Mozambique and heavy cuts in

Cambodia and Guatemala.

The budget for prevention for female sex workers (FSW) also reduced or stayed the same in three

out of five countries, only increasing in Cambodia, where there was focused effort to increase

targeted programming to this group (and other KVPs) via improved management and support for

outreach workers.

Box 2.1: Mozambique HIV/TB investments to address equity-related barriers.

The NFM2 grant making process reduced investments to address HRG-Equity-related barriers

in Mozambique by 25% (from US$46m to US$34m), mainly driven by a US$6m (68%) reduction

in HR-related investments and a US$3m (30%) reduction in wider KVP investments.

These

reductions were partly offset by a substantial increase in funding for prevention among

adolescent girls and young women (AGYW), from US$6m to US$14m, in response to emergent

evidence of increasing incidence among this group. Of note, anticipated matching funds for

human rights (US$4.7m) were added after the grant award, so appear in the first

implementation letter. For human rights, it was felt the strategy was not complete and the

implementation therefore was also not ready, so the Grant Approvals Committee (GAC) agreed

to delay the start and reduce the budget from the core allocation without jeopardizing eligibility

for matching funds. For AGYW, the budget from the core allocation was increased to support

more activities for this group.

Figure 4. NFM2 HIV/TB funding request and grant award budget variance analysis of investments

designed to address HRG-Equity or other barriers to accessing health services and/or achieving

health outcomes:

Source: Global Fund

detailed budgets

There was also a US$8m (98%) reduction in funding for Prevention of mother-to-child transmission (PMTCT) —

reflecting the shift from Option B+ to test and start. The related increases in testing and treatment costs were included

in other budget lines, notably treatment care and support, which is not included in our estimates of equity-related

investments at grant award.

RSSH Investments

Analysis of RSSH budget changes during grant making shows large increases in some countries

and significant declines in others, as well as substantial shifts between modules/program areas

in many countries. Three PCE countries increased the overall RSSH allocation from funding

request to grant award (Cambodia, DRC, Guatemala) and three countries decreased the overall

RSSH allocation (Mozambique, Myanmar, Uganda). In all countries, the final agreed level of RSSH

investment was below what was recommended by the Secretariat (which varied from 5% to 11%

of total grant value across countries) and the vast majority of the agreed NFM2 RSSH investments

were designed to support rather than strengthen the health system.(4)

RSSH module budgets shifted in different ways during grant making. Four out of seven PCE

countries with available data (excluding Sudan) increased resources for the Health Management

Information System and Monitoring and evaluation (HMIS/M&E) module and three countries

increased resources for Procurement and supply chain management (PSM)—two areas critical to

supporting core disease grant implementation. Guatemala introduced a substantial increase in

HMIS and M&E in response to TRP comments (discussed further below). In Mozambique,

investments for integrated service delivery (ISD) and quality improvement, which were relatively

limited in most PCE countries, declined significantly during grant making. Three countries

reduced resources allocated to community responses and systems between the funding request

and grant award, with negative implications for equity, given the role of these systems in reaching

the most vulnerable, and for achieving sustainability objectives. Value for Money (VfM)

considerations sometimes drove reductions. In Uganda, for example, per diem allocations for

community systems strengthening (CSS) outreach were reduced in alignment with the

government’s policy on rates.

Key message 2: Several business model factors, including the role of the Secretariat

Country Teams (CT), matching funds and the TRP review process, influenced prioritization

during grant making.

A range of country-specific and Global Fund business model factors affected prioritization

decision making during the grant making process. As compared to the relatively open and

transparent funding request development process, grant making was difficult to observe from an

evaluation perspective, with many discussions taking place in private between senior Secretariat

staff and country stakeholders. Nonetheless, evidence suggests that the most significant business

model factors influencing the design of grants were:

Role of the Secretariat: Across all PCE countries, qualitative evidence suggests that the

Secretariat played an important role in working alongside country stakeholders to guide

prioritization decision making. This included working with country stakeholders to revise initial

funding request submissions prior to TRP review, and in interpreting the recommendations made

by the TRP and GAC to finalize grant designs and budgets. In some countries, the Secretariat has

a ‘hands on’ role, such as in the DRC, where the budget for HIV testing among KVPs was reduced

during grant making to accommodate a Secretariat request to partake in the Supply Chain

Transformation Project, and the CT asked Principal Recipients (PRs) to identify budget cuts

across various modules to make US$10m available.

Matching funds: Five out of eight PCE countries received catalytic matching funds that served to

increase total investment in HRG-Equity-related areas. However, evidence is mixed on whether

these funds had the desired effect of increasing the level of investment to these areas made from

the core country allocations. Although in Mozambique, the human rights budget reduced (Box

1.1), for most countries receiving human rights matching funds (DRC, Senegal, Uganda), the total

budget from the core allocation increased for this priority area during grant making. By contrast,

of the three PCE countries that received matching funds for RSSH/data systems, the related

budget from the core allocation decreased in Mozambique, while in DRC it increased. In Myanmar,

although the allocation to RSSH from the HIV budget increased, the overall allocation to RSSH

declined due to TB grant reductions.

Box 2.2: Drivers of AGYW intervention shifts during grant making in Uganda.

The total investment in interventions within the AGYW module remained relatively unchanged

after grant making, decreasing 1% from US$5.0m to US$4.96m. However, there were substantial

shifts across four of the seven AGYW intervention areas budgeted, mainly in response to TRP

comments on the matching funds application requiring iteration. Per the TRP comments, the

proposed matching funds were spread across too many interventions and geographies, and

some interventions were unrelated to the proposed outcomes. During grant making, the PRs

and CCM adjusted the AGYW interventions in the HIV grant’s main allocation and revised the

matching funds submission to remove activities that did not contribute directly to accelerating

progress and enhancing outcomes among vulnerable AGYW. The reductions in the

socioeconomic approaches, community mobilization, and other AGYW interventions created

room for an increase of US$3.4m in the main HIV grant activities focusing on keeping girls in

school interventions, which had no allocation in the original funding request.

Figure 5. NFM2 funding request to grant making budget variance for select AGYW interventions:

Source: Global Fund detailed budgets in Uganda

TRP review process: TRP comments and recommendations influenced the grant design and

budget in several countries. For instance, following the TRP comments in Mozambique, during

grant making the PR placed significant emphasis on prevention among AGYW and reduced

budgets for prevention among other KVPs. TRP comments in Uganda contributed to narrowing

the focus of AGYW intervention areas during grant making with the aim of maximizing investment

into interventions with a strong evidence base, that would significantly reduce the HIV risk

among AGYW. Another example from Myanmar is provided in Box 2.3.

Box 2.3: Effect of TRP comments on equity investments during grant making in Myanmar.

One of the TRP comments on the NFM2 funding request was a request to expand service

coverage for HIV testing and methadone maintenance treatment (MMT) for PWID. Following

grant negotiations with the Secretariat, the two PRs increased targets for reaching PWID with

HIV prevention, testing and MMT for the NFM2 grant period through cost efficiencies in

prevention activities: PWID HIV prevention targets increased by 16%; the PWID tested target

increased by 32%; and the PWID on MMT target increased by 38%. The revised targets were

confirmed by the GAC for the grant award.

Box 2.4: Effect of TRP comments on RSSH design during grant making in Guatemala.

During grant making, the HMIS budget more than doubled in direct response to comments from

the TRP. Noting persistent weaknesses in the ability of the national HMIS to track program

indicators and monitor progress, the TRP requested a detailed plan to strengthen HMIS and

better monitor progress toward epidemic control and recommended consideration of DHIS2 as

a platform. As a result, the PR INCAP added US$500,000 to the program and data quality

intervention, to support the strengthening of the national HMIS and develop a system to enable

to PR to track relevant community level indicators. This targeted investment for the PR was

aligned with a national HMIS strengthening plan that had identified DHIS2 as an option for wider

HMIS strengthening endeavors and was presented by the CCM and PR as the response to the

TRP comments. Despite the increased investment in HMIS, no additional relevant indicators

were added to the performance framework.

2.2: NFM2 grant implementation

Implementation Progress

Key message 3: A number of Global Fund business model factors influenced grant start-up

and early implementation, especially: lengthy selection and contracting processes for

implementers and CT support. Early implementation delays disproportionately affected

RSSH and HRG-Equity activities.

NFM2 grant implementation was significantly disrupted, both by delays to start-up in Year

1 and by the onset of the COVID-19 pandemic in Year 3. Across PCE countries, a number of

Global Fund business model factors resulted in initial start-up delays in Year 1 of NFM2 grant

implementation, discussed further below. Overall Year 1 absorption for all modules across all

grants ranged from a low of 54% in Cambodia to a high of 74% in Myanmar, with an average of

68% (Figure 6). Implementation progress accelerated in Year 2 in nearly all PCE countries as

implementers overcame start-up delays and in some cases put in place accelerated or ‘catch-up’

implementation plans. Average absorption across PCE countries was 81% (see Figure 6 and

Annex 6). Based on available data for the first half of Year 3 (2020) in a subset of countries (DRC,

Senegal, Uganda), we observed lower absorption compared to Year 2. Evidence suggests that this

is partly due to challenges in implementation resulting from the COVID-19 pandemic. However,

the cumulative effect of budget revisions resulting in unutilized budgets from earlier years being

shifted to the final year of grant implementation also contributed to low absorption in Year 3.

Compared to the grants’ overall average progress, implementation remained particularly

slow in some RSSH and HRG-Equity-related investment areas. At the most recent time point

where data are available (2019 S2 or 2020 S1, depending on the country), seven of eight PCE

countries had lower cumulative absorption for HRG-Equity investment areas compared to the

overall grants, and all eight PCE countries had significantly lower cumulative absorption for RSSH

investments compared to the overall grants (see Figure 6).

Financial absorption is defined as the

percentage of the budget that was spent within a given time period. However, as noted in previous

PCE reports, absorption is an imperfect measure of implementation progress as it does not

RSSH absorption was 15 or more percentage points below total absorption in all countries, and in half of the PCE

countries (Mozambique, Senegal, Sudan, Uganda) it was 30 or more percentage points lower.

capture the quality of implementation and may incentivize implementers to focus on activities

that are more quickly absorbed.

Figure 6. NFM2 cumulative absorption over time for all modules, HRG-Equity-related

investments, and RSSH investments

Figure note: 2020 absorption only includes S1; Guatemala grants began NFM2 implementation later.

Source: PU/DRs

As summarized in Figure 7, and explored in more detail below, a number of Global Fund business

model factors influenced implementation progress during NFM2, with some particularly affecting

the grant start-up phase in Year 1.

Figure 7. Global Fund business model factors influencing implementation progress

Lengthy selection and contracting of implementers, particularly SRs by PRs, delayed

implementation of activities in the majority of PCE countries. In Sudan, the new PR undertook

capacity assessments with 14 new SRs and Implementing Units but not sufficiently in advance of

grant implementation, causing significant delays. In Cambodia, DRC, Mozambique, Senegal and

Uganda, disbursements to SRs did not occur until the second or in some cases third quarter of

2018 as a result of SR contracting delays due to weak capacity. SR contracting delays during grant

Each of the factors have been weighted in the form of a score based on their relative level of influence over grant

implementation, where five (5) is the most important and one (1) the least (noting that the least important factors are

not included to aid readability).

start-up particularly affected the implementation of HRG-Equity activities as PRs often rely on

SRs with community experience to deliver KVP, HR and gender interventions and these

organizations have less experience with Global Fund management systems. In other cases, new

government PRs, appointed to enhance sustainability, had relatively little experience with Global

Fund processes, resulting in early implementation delays. For example, Cambodia appointed the

Ministry of Finance as PR for NFM2 to promote national ownership and sustainability, which led

to a slow grant start-up in year 1 due to disbursement delays, but subsequently implementation

picked up pace (see also Senegal example in Box 2.5).

Box 2.5: Senegal new government PR lack of familiarity with Global Fund processes.

For NFM2, Senegal moved to consolidate and centralize responsibility for grant management

within the Ministry of Health to create efficiencies and streamline ownership. As recommended

by the CCM, the Secretariat awarded PR-ship of the TB/RSSH grant to the Direction Générale

de la Santé/Direction de l’Administration Générale et de l’Equipement (DGS/DAGE), while the

national TB program, the former PR, became a sub-recipient. These implementation

arrangement changes affected roles and responsibilities across different Ministry of Health

actors, and, along with the DAGE’s relative inexperience with Global Fund procedures as a new

government PR, caused implementation delays, which stakeholders attributed to the absence

of a transition phase between allocation cycles and inadequate consideration of onboarding

needs to support new PRs.

Box 2.6: Sudan new PR lack of familiarity with Global Fund processes inhibited malaria

grant implementation.

Under NFM2, the PR for the malaria grant transitioned to the Ministry of Health (MoH),

although government financial and management systems did not fully meet standard Global

Fund requirements. Throughout NFM2, extreme political and economic upheaval severely

impacted on the delivery of the malaria program, partly due to PR lack of familiarity with the

Global Fund business model. Together, these factors limited disbursement and delayed

implementation and absorption, particularly for routine LLIN distribution. Despite these

problems, in 2019 the GAC approved a budget of $25 million for LLIN mass distribution.

Concurrent Global Fund processes were a barrier to implementation progress. Most PCE

countries spent the first six months of NFM2 grant start-up simultaneously closing NFM1 grants.

These concurrent processes were reported as time-consuming in several PCE countries (Sudan,

Myanmar, Uganda) and reduced time and attention from grant start-up activities, even in the case

of program continuation grants.

Aligning budgets and implementation plans for Global Fund grants was a highly complex

process. As observed across all PCE countries, the advantages of input-based budgeting in terms

of risk management did not outweigh the complexity of subsequent changes to implementation

plans. In Myanmar, budgetary management tools inhibited implementation in a number of ways.

For instance, the managed cash flow system, introduced as a financial risk mitigation measure,

contributed to low budget absorption, alongside high program management costs. Intensive

reporting and data verification processes also took significant time for PRs to deal with,

detracting their focus from implementation.

Finally, some countries did not approve Matching Funds and related disbursements until well

into the NFM2 grant implementation period. This misalignment with the main grant approvals

negatively affected the implementation of those activities and had a significant effect on RSSH and

HRG-Equity activities, as they rely more on matching funds and take significant time to plan. In

DRC for example, the Secretariat processed matching funds for RSSH/data systems separately

from the main grant and they did not go through GAC approval until eight months into NFM2

implementation. Similarly, in Uganda, misalignment of timing of matching funds for AGYW and

Human Rights, due to the matching funds request sent back from TRP for iteration, delayed

signing of MoUs with public sector SRs, causing further implementation delays. Senegal also

experienced significant delays in the incorporation of matching funds.

Influential enablers of early implementation progress during NFM2 included the role of CTs in

resolving early bottlenecks and employing flexibilities to Global Fund requirements and the

process, flexibility and timeliness of fund disbursements from the Global Fund Secretariat to

PRs—most PCE countries received initial disbursements on time. In Uganda, DRC, Cambodia and

Senegal, the CTs played an important role in allowing for flexibility in the disbursement of funds

to avoid disruption to grant implementation. In Myanmar, stakeholders reported that alignment

with the National Strategic Plan (NSP) and the CCM coordinating partners also supported

implementation.

Key message 4: After grant start-up, weak grant coordination as well as issues with

performance monitoring constrained ongoing implementation progress. Again, these

factors particularly affected RSSH and HRG-Equity-related activities. Conversely,

stakeholders’ engagement in regular progress reviews and grant coordination meetings

facilitated implementation.

As summarized in Figure 7 above, a number of Global Fund business model factors influenced

implementation progress in Years 2 and 3. Most notably:

Weak coordination within and between grants, with other program teams and between donors,

constrained implementation in multiple PCE countries (Cambodia, DRC, Guatemala, Senegal and

Sudan). Coordination challenges particularly affected RSSH investments, in part due to resources

for RSSH activities being spread across grants, and because responsibility for the aspects of health

systems being targeted often lies outside of the disease programs. As a result, a diverse set of

stakeholders needed to be involved in grant design and implementation, which evidence suggests

was lacking in many countries. Where RSSH funds and activities were provided through the

disease-specific grants, stakeholders found it challenging to implement activities that were

intended to be integrated across diseases (see Box 2.7). In DRC, governance and coordination

challenges stymied implementation of digital health interventions following the government’s

creation of a new digital health agency with responsibilities overlapping those of the national

health information systems agency. In Senegal (Box 2.7), the Secretariat lacked an accountability

mechanism for ensuring follow-through and/or intervention, although between NFM2 and NFM3,

a strategic shift centralized management of TB and Malaria grants under a single unit within the

MoH, which may help address both coordination and leadership issues in the future. These

examples highlight that coordination and leadership are needed to implement activities with

objectives beyond the disease grants.

Box 2.7: Senegal RSSH coordination challenges. In Senegal, each disease program grant was

expected to contribute 10% of its RSSH budget to support the multi-sectoral RSSH platform,

created to improve coordination and harmonization of crosscutting RSSH activities under the

Ministère de la Santé et des Affaires Sociales (MSAS) Direction Générale de la Santé (DGS),

which was selected as the PR of the TB/RSSH grant. However, only the TB program allocated a

portion of their funds, while the HIV and Malaria programs did not because they were unclear

how the funds would be used. This contributed to the platform’s already weak financial and

logistical management capacity, and undermined efforts to integrate RSSH investments across

all three disease programs.

Some PCE countries have examples of successful approaches to overcoming coordination

challenges. In Mozambique, initial delays in recruitment of an RSSH lead delayed implementation

of critical RSSH investments. However, once that position was filled, their leadership facilitated

RSSH implementation progress. In other countries (DRC, Guatemala), support and/or persistent

follow-up from the CT supported RSSH implementation progress.

While weak grant coordination was identified as a common implementation constraint, a number

of other mechanisms strengthened these functions and leveraged national leadership and

country ownership over grant implementation. In some cases, the CCM ensured broad and

diverse engagement of stakeholders in a number of countries, particularly in Myanmar.

Regular progress reviews and grant coordination meetings, supported by CTs, also enabled

progress. In DRC, Uganda and Senegal, these reviews and meetings at national and/or subnational

levels facilitated coordinated implementation progress. In Mozambique, coordination of the grant

with the wider MoH program similarly facilitated implementation. Conversely, where there are

examples of lack of political support and the above levers were not suitable and/or used to good

effect, this negatively affected implementation—for instance, with a lack of progress made in

implementing activities to strengthen DHIS2 in Senegal.

Issues with performance monitoring and grant management inhibited implementation

across PCE countries. The Global Fund has designed performance frameworks to include

indicators that are helpful for tracking overall country progress but less useful as indicators to

measure grant implementation progress or results. Moreover, NFM2 performance frameworks

lacked specificity on key RSSH and HRG-Equity investments. Where indicators were proposed,

poor data quality often hampered their use (see Box 2.10 and 2.11).

The grant revision process, discussed in more detail in the section below, was also a barrier to

implementation progress. While the Global Fund intended grant revisions processes to enable

implementation adjustments to maximize impact, in practice, stakeholders found the process

burdensome and have sought to avoid undergoing significant changes that would trigger a TRP

review. In contrast, the grant revision processes for COVID-19 revisions were perceived as more

flexible and a lighter lift for country stakeholders, which has enabled rapid implementation

adjustments in 2020 (see Box 2.8), and may be a source for lessons learned in addressing some

limitations of the standard revision processes.

Box 2.8: Grant implementation and COVID-19 disruptions. Evidence from the PCE countries

underscores how COVID-19 particularly affected HRG-Equity investments in NFM2. For

example, the social distancing measures in Uganda as part of the COVID-19 response included a

ban on social gatherings and movement, as well as school closures, which affected activities like

dialogues, sports campaigns, outreach, and in-school activities that targeted AGYW to reduce

gender barriers to HIV prevention, care, and treatment. COVID-19 also affected HIV services for

KVPs in Cambodia, as described further below.

Equity implications of COVID-19 on delivery of HIV

services for key populations in Cambodia. By the

end of 2019, KVP outreach targets had largely been

met and/or exceeded, with the exception of PWID

(not shown). As a result, in 2019, the grant increased

resources for these services through portfolio

optimization and revisions, shifting funds to the

stronger performing interventions targeting Female

Entertainment Workers (FEW), MSM and

transgender people. However, during 2020, COVID-

19 restricted achievement of targets for all key

populations, especially FEW and PWID (not shown).

Entertainment venue closures triggered FEW to

migrate, which disrupted outreach contact. Some

stakeholders expressed concern around the capacity

of implementers to deliver on additional services

under COVID-19 and its effect on absorption.

Global Fund business model flexibilities were

critical in channeling additional resources to the COVID-19 national response through

grant savings and the COVID-19 Response Mechanism (C19RM). Countries used flexibilities

within the NFM2 grants through a mix of ‘true’ savings (e.g., delayed implementation over Year

1-2, lower unit costs, over-budgeting, etc.) and savings from activities that could not be

implemented during lockdowns (e.g., outreach, training, meetings, supervision, school-based

activities), revising US$26m from current grants. An additional US$209m was approved

through C19RM. PRs and SRs undertook various implementation adaptations in responding to

COVID-19 disruptions. For example:

● Cambodia: COVID-19 was predicted to affect antiretroviral therapy (ART) attendance, so

implementation shifted to providing multi-month scripting for all stable ART patients to

ensure maintenance.

● Guatemala: To limit face-to-face outreach interactions, a SR switched to online outreach for

KVPs, with early evidence of improved performance.

● Myanmar: Additional procurement for ARV buffer stock through October 2021, treatment

for opportunistic infections and methadone maintenance, rapid test kits.

● Senegal: Strengthen procurement and supply of laboratory equipment and reagents in

reference labs and potentially increasing use of GeneXpert for COVID-19 testing.

● Uganda: Innovations that leverage Global Fund investments, such as using the bed net

campaign database to guide distribution of facemasks to households, or utilizing community

health volunteers to support medication refill and distribution.

Table 2. Approved grant flexibilities and C19RM ($US millions).(5)

Mechanism

CAM

DRC

GTM

MOZ

MYN

SEN

SDN

UGA

Total

Flexibilities

$0.52

$2.3

$2.6

$6.3

$2.2

$1.6

$10.5

$26.1

C19RM

$55.1

$1.1

$60.5

$27.3

$4.9

$8.7

$51.9

$209.5

The role of revisions during implementation

As per the Operational Policy Manual: “The goal of a grant revision is to allow Global Fund

investments to adjust to programmatic requirements during grant implementation, in order to

ensure the continued effective and efficient use of Global Fund resources invested to achieve

Figure 8. Percentages of FEW reached and

tested by KVP outreach program

maximum impact in line with the Global Fund’s 2017-2022 Strategy. A grant revision may also occur

due to other changed circumstances and arrangements.”(6) Grant revisions include:

● Additional funding revisions: When the total approved funding is adjusted, including

through ‘portfolio optimization’ and additional donor pledges.

● Program revisions: When programmatic changes in the scope (changing goals,

objectives, or key interventions) and/or scale (increasing or decreasing targets) are

applied to the grant (formerly referred to as “reprogramming”).

● Budget revisions: When the budget is adjusted but the total approved funding does not

change, nor is there any effect on the performance framework.

In addition, subject to its review of grant performance, the Secretariat makes an annual funding

decision that determines the proportion of the grant budget that will be disbursed in the following

period. This is in effect how the Global Fund’s performance-based funding model is

operationalized—i.e., the full budget is disbursed where grant performance is strong, but a

proportion of the budget is withheld where grant performance is weak (see Annex 7). As such, in

theory these decisions also influence whether and how grant revisions are made. The cumulative

effect of these various processes is a grant budget that is frequently subject to change and highly

complex. We explore the implications of these processes for grant management and

implementation in the findings below.

Key message 5. The burdensome revisions process, alongside management incentives on

PRs and CTs to maximize absorption, resulted in revisions being used predominantly as a

financial management tool, rather than necessarily to maximize impact. The cumulative

effect was that grants shifted resources to later in the cycle rather than undergoing

significant restructuring to the scope and/or scale of grants, having the potential to reduce

allocative efficiency.

PCE countries made frequent budget revisions (N=38) and additional funding revisions

(N=37), but program revisions (N=17) to scale or scope were uncommon (Table 3).

Table 3. Number and type of grant revisions during NFM2

CAM

DRC

GTM

MOZ

MYN

SEN

SDN

UGA

Total

Additional Funding

Revision

Budget Revision

Program Revision

Total

Table 4. Number of grant revisions and length of approval process by revision type during NFM2

Type of revision

Number of

revisions

Average revision approval

duration (days)

Average revision

approval date

Additional Funding Revision

132

11/7/2019

Budget Revision

4/22/2020

Program Revision

12/5/2019

Grand Total

1/15/2020

The PCE did not examine the other two types of revisions defined in the Operational Policy Manual: Extensions (End

Date Revisions) and Administrative Revisions.

As shown in Figure 9, a range of incentives drove grant revision decision making. Additional

funding revisions tended to occur earlier in the grant lifecycle, be initiated by the

Secretariat and negotiated between the CTs, CCMs and grant recipients, and were based on

reviews of high-priority activities approved in the register of unfunded quality demand

(UQD). Decision makers used funds to fill gaps and reinforce approved grant strategies, including:

increasing the investment in community TB care delivery in Cambodia; maintaining vector

control coverage and covering the 2020 ART gaps in Mozambique; providing emergency funding

for refugee LLINs and filling case management gaps in ACTs, in Sudan, alongside filling gaps in

IRS and LLIN mass campaigns in year 3; expanding geographic coverage of the LLIN campaign

and HIV testing and treatment in DRC; and incorporating funds from Comic Relief to ramp up

efforts to eliminate mother-to-child transmission of HIV in Guatemala.

Evidence from Cambodia suggests that the process for selecting what activities/interventions are

supported with the additional funding can be problematic. Specifically, despite national

stakeholders being encouraged by the Secretariat to put forward innovative programming

proposals, the Country Team aligned with TRP approved proposals, although the process through

which these decisions were made became a source of frustration and disillusionment among

national stakeholders

Figure 9. Available information and incentives drive decisions and influence grant revision

processes.

Most PCE countries undertook frequent budget revisions (reallocation), in order to

improve financial performance and maximize absorption. In Cambodia, for instance, where

the PR shifted funds away from poorly absorbing (and performing) PWID activities and into

better absorbing (and performing) FEW/MSM/transgender interventions. DRC was a notable

exception because it did not undergo any budget revisions, but, compared to other PCE countries,

had the most program and additional funding revisions. Tracking budget revisions is time-

consuming and lacks a systematic process of documentation, which has implications for

transparency beyond the PRs and LFA. Implementation letters (when official budgets are

updated) did not generally document budget revisions, which meant PCE teams examined budget

revisions through detailed comparison of official budgets over time.

Only four PCE countries executed program revisions. Revisions resulted from various triggers

(e.g., changes in implementation arrangements, in response to absorption issues, and/or

administrative issues—such as shifting funding between PRs in DRC due to changes in commodity

and freight unit costs). DRC had the most program revisions compared to other PCE countries,

which is likely a reflection of the portfolio size and complexity. However, the broader trend across

PCE countries suggests that program revisions were an underutilized mechanism for executing

changes in programmatic scope and scale. At the midpoint of the grant lifecycle, PRs did not want

funds to be withdrawn from their grant budgets, nor did they want to introduce new

programmatic activities (particularly for RSSH) that would be difficult to implement and may not

align with grant performance framework targets. Furthermore, the burdensome grant revision

process, particularly for program revisions, acted as a disincentive to undertaking substantial

grant revision. As shown in Table 4, program revisions took on average 52 days for approval.

However, this average duration does not include any ‘material’ program revisions requiring TRP

or GAC reviews, as none occurred in PCE countries in part due to the perceived burdensomeness

of the process; material program revisions would likely have taken longer on average. Limitations

to programmatic evidence available to inform grant revisions also restricted the ability of PRs,

CCMs and CTs to revise grants based on data/evidence about programmatic results or impact (in

line with the objective to ‘maximize impact’).

Box 2.9: AGYW investments in Uganda underwent frequent budget revisions by the civil

society PR, whereas the government PR appeared to miss opportunities for revision. The

civil society PR made budget revisions within the AGYW module, in some instances resulting in

a 60% increase/decrease to intervention totals, but did not introduce changes to targets. They

viewed budget revisions as necessary to improve absorption and responding to AGYW

beneficiaries’ preferences for vocational training offerings (with sustainability implications of

improving AGYW livelihood opportunities). Despite several budget shifts, the overall total

investment remained roughly stable at US$10m. Stakeholder interviews indicated that they

viewed matching funds as ‘protected’ or ‘sacred’—and that this drove efforts to ensure any

budget reallocation retained the funds within the AGYW module. The government PR did not

undertake similar budget revisions for AGYW interventions, despite ongoing delays in

implementation through 30 months of the grant, and only three of six interventions registering

any expenditure as of S1 2020 (cumulative 1.49% absorption). However, in September 2020, the

Ministry of Education, an SR, in consultation with the government PR, proposed 38% of its AGYW

module allocation be reallocated toward the prevention of gender-based violence, which was

approved by the CT. This example highlights evidence of COVID-19-related revisions aiming to

incorporate equity considerations, including programming to address the indirect impacts on

young people resulting from COVID-19, including increased gender-based violence, teenage

pregnancies and HIV infections among AGYW.

Box 2.10: Mozambique did not use grant revisions to rectify a known issue with the budget

versus target linking HIV+ FSWs to care. The recently established FSW program had funding

doubled during NFM2 grant making, but with targets set low based on relatively out-of-date KVP

data estimates (in spite of the TRP’s recommendation to scale up targets). The SR, FDC, initially

overachieved targets for outreach and testing, so grant performance was rated high. However,

partly because of the way targets are calculated in the prevention cascade, in reality the program

missed many HIV-positive FSW for linkage to care. In addition, FDC responsibility for linkage

ended with one visit to the closest health center, and they made no effort to follow up or ensure

clients fully entered into treatment. During implementation, the CT did not revise linkage targets

upwards as the budget did not increase and no grant revision took place. The CT did draw

attention to the women missed for linkage to ART, so FDC are altering their model of service

delivery for NFM3.

Box 2.11: DRC did not use grant revisions to adjust differentiated HIV testing targets

following new data on HIV incidence. DRC submitted a tailored review NFM2 funding request

for HIV/TB because the HIV component remained largely unchanged due to NFM1 grant delays

In particular, this refers to data on absorption being a weak proxy for implementation progress, limited quantitative

and standardized evidence available on grant implementation progress, grant performance framework indicators not

reflecting grant-specific results and not having any indicators in some important areas of the grants (often for RSSH),

and limited utilization of Work Plan Tracking Measures (WPTMs).

and lack of new epidemiological data. HIV grants were thus approved by the GAC with the

understanding that KVP testing targets would be updated during grant implementation

following the results of the 2017 HIV incidence study. However, by the time the new data on HIV

incidence were released in Q1 of 2020, development of the NFM3 funding request was already

underway and both the CT and PR considered it too late in the NFM2 grant cycle to undergo a

grant revision. This example highlights challenges with the business model of responding quickly

to new data and changes in programmatic and epidemiological context, but also raises

limitations in monitoring grant performance. For example, by semesters 3 and 4, HIV tests

administered to KVPs largely exceeded grant targets although it was acknowledged that the

under-estimated targets were driving the indicator performance.

In most PCE countries, PRs and CTs responded to low absorption of RSSH and HRG-Equity

budgets by shifting unused resources to later in the grant cycle rather than to higher-

absorbing program areas. For HRG-Equity-related areas, grant revisions mostly had the net

effect of increasing the budget. As depicted in Figure 10 (left), at the beginning of implementation,

investments related to HRG-Equity made up between 7% and 30% of PCE country budgets, with

an average of 16%. Of these investments, across countries the majority consisted of KVP-related

investments, followed by other equity-related investments and lastly, human rights. At the most

recent official revision observed by the PCE, funds for HRG-Equity had increased in all countries.

Grant revisions had a mixed effect across countries on the budget for RSSH. RSSH-related

investments during implementation decreased or remained fairly constant in half the PCE

countries while the other half observed increases (Figure 10, right). However, as a share of total

budgets, RSSH investments on average decreased from 11% to 9% across all countries.

Figure 10. HRG-Equity (left) and RSSH (right) related investments during implementation

Source: Global Fund detailed budgets

Using budget revisions systematically to shift unutilized resources from Year 1 to Years 2

and 3, and subsequently from Year 2 to Year 3, has potential to reduce allocative efficiency.

For example, in Myanmar (Figure 11), the HIV/TB grant budget reduction in Year 1 raised

absorption against the originally approved grant budget, with implications for grant

management. While it makes sense to shift resources to later in the grant cycle if this ensures that

they are well used, substantial sums were involved (around US$15m in the Myanmar example)

and the processes in place to make budget revisions were informal and did not require any form

of approval outside of the CT. When resources are moved around mid-cycle, the significant

benefits of the NFM model in terms of the predictability of funds are also eroded. Furthermore,

the accumulation of budget in the last year of the grant cycle places additional pressure on PRs

and SRs to avoid the Secretariat reallocating the resources through portfolio optimization.

Although the PCE has not yet been able to collect evidence on this as 2020 budgets had not been

published at the time of writing, other reviews, including SR2020, linked this situation to a

dramatic increase in spending on commodities in the final year of NFM1 grants and questioned

whether this was a good use of funding.

Analysis shows that the effects noted above were more pronounced for modules and/or

intervention areas where absorption is low in the early years of implementation. As shown above,

this affects both RSSH and HRG-Equity-related investments, which also often require more time

to plan for and implement than other investment areas. Box 2.12 provides an example from

Mozambique.

Figure 11: Comparison of the Myanmar HIV/TB grant budgets between Funding Request, grant

award and latest Official Budget Revision (OBR) (2019).

Source: Global Fund detailed budgets

Box 2.12: Delayed implementation of RSSH interventions in Mozambique. The budget for

RSSH within the HIV grants for 2018-20 was US$23m at grant award and US$27m as per the

latest grant revision, including an additional US$3m from matching funds. Based on cumulative

rate of absorption at mid-year in final year of grant, which was approximately 50%

, a large

amount of the funds would be unspent by the end 2020. At mid-2020, expenditure for the largest

investments—activities primarily designed to support health systems—was below budget, but

investment areas designed to strengthen the health system were even worse. The exception is

community responses and systems, for which the budget was reduced during grant making. Low

absorption partially stems from the delay of appointing a coordinator/lead for RSSH until May

2020. Despite low absorption, the grant did not use revisions to shift funds away from RSSH to

other programmatic areas, as funds were already committed in RSSH procurement processes.

Rather, as shown in Figure 12 below, the PR and CT shifted unused resources to later in the

grant. Despite this, a significant increase in resources for RSSH is planned during NFM3.

Stakeholders report that, although the NFM business model has increased predictability for

RSSH funding, the three-year cycle does not lend well to strengthening and sustaining

improvements in the health system.

Figure 12: Budget variance for Mozambique NFM2 HIV grants, RSSH modules only, 2018-2020,

by year

Source: Global Fund detailed budgets

Key message 6: Global Fund disbursements to countries often varied from the total budget

for each period but were not linked to indicator or grant performance ratings. As such, this

element of the business model does not appear to be working as intended to incentivize

performance.

The Global Fund seeks to incentivize performance, in part, by linking disbursement amounts to

the achievement of grant targets (summarized through an indicator rating, which informs an

overall grant rating).

As shown in Annex 7, disbursements often varied dramatically from the total agreed budget for

each reporting period.

Even where performance against the indicators within each grant

Information provided following the end of data collection for this report suggests absorption was over 90% by end of

December 2020, reportedly due to a significant increase in expenditure at the end of the grant cycle related to

procurement of commodities.

For instance, as shown in Annex Table 6.3, disbursements for 2018/19 exceeded the total original budget for this

period in 15 out 30 grants.

performance framework was weak (e.g., for some grants in Mozambique, Uganda and Senegal),

Secretariat disbursements were often above or a relatively high proportion of the total grant

budget.

Although indicator performance provides only a ’starting point’ for determining

disbursements, the lack of any relationship across all grants in PCE countries suggests that the

annual funding decision is not working as intended to operationalize the principle of

performance-based funding.

As noted in the sections above, analysis conducted through the PCE and elsewhere (e.g., SR2020)

suggests that this may be a function of:

a) The grant monitoring system being focused mostly on reporting progress against national

program-wide indicators rather than reporting the results of the Global Fund grant

specifically, and therefore not being a good proxy for grant implementation and

performance;

b) Limitations of grant performance frameworks, for instance where they include

weak/unrelated indicators with unrealistic targets, and/or where important investment

areas are omitted from the performance framework (e.g., human rights, RSSH), reflecting

wider measurement challenges.

(7,8) This is particularly true when considering how few

indicators are reported for some semesters.

The quantitative evidence on which to base disbursement decisions (and decisions on grant

revisions) to ensure they incentivize appropriate and optimal behavior is therefore limited. The

Mozambique example in Box 2.10 highlights a specific example of the difficulties faced in

measuring grant-specific progress. A number of PCE CEPs also reported that disbursement

decisions are made primarily based on financial needs, and possibly also qualitative information

on performance. The Secretariat may also consider it inappropriate to reduce funding to poorly

performing grants after only a year of implementation.

Nonetheless, the lack of clarity over how

the system works and how funding decisions are made may undermine the performance-based

funding model.

Box 2.13 provides an example of how disbursements decisions were made for a grant in

Mozambique.

Box 2.13: Disbursement decisions encouraged the achievement of results for a grant in

Mozambique with a troubled start

The Collaborating Centre for Health (CCS) HIV/TB grant achieved an indicator and grant rating

at the end of 2018 of B2 (inadequate but potential demonstrated). Correspondingly, the OPN

suggests that between 30% and 59% of the cumulative budget for 2018 and 2019 should be

disbursed in 2019.(6) While this is indicative and can be adjusted, analysis shows that

disbursements were much higher, at 94%. The CT confirmed that disbursement decisions were

made to manage financial resources, as well as performance. However, reducing funding to low

performing grants may not be the best way to maximize results. The indicator and overall grant

rating for this grant increased dramatically to A2 (meeting expectations) by the end of 2019.

As shown in Annex Table 6.3, the level of disbursements made is substantially different to the indicative funding

range for 19 out of 30 grants.

Ref previous PCE synthesis report, SR2020. For example, previous OIG analysis of 27 grants found that nearly 30%

of the budget was not reflected in the performance framework.

It is also worth noting that doing so may affect grants with a strong focus on activities that take more time to plan

and start implementation (e.g. those focused on RSSH, human rights, etc.).

Chapter 3: Lessons learned NFM2 to NFM3

As shown in Chapter 2, the ability of grant managers (both Secretariat teams and country

stakeholders) to adjust grants mid-term is fairly constrained, in part due to burdensome formal

revision processes and the significant disruption that these revisions potentially pose for

implementation. As also shown in Chapter 2, grant managers have few incentives to undertake

revisions that include scope/scale adjustments to grants; and instead tend to shift the unutilized

budget to later years in the grant cycle and delay major structural decisions until the next funding

request application. Ensuring grants are well designed at the time of the grant award is therefore

critical.

In this chapter, we therefore explore PCE findings on how the grant design process was informed

by lessons from NFM2, NFM3-specific elements of the business model, and new information and

policy to determine grant priorities, budget allocation and performance framework elements.

Key message 7: In most PCE countries, the NFM3 funding request process was an

improvement on NFM2: more streamlined, efficient and flexible; characterized by

improved country ownership and participation by a wider group of stakeholders; and with

a range of business model factors used effectively to influence grant priorities.

NFM3 ‘Tailored for NSP’ and ‘Full Review’ processes were found to be more efficient than

NFM2 ‘Full Review’ processes. Just two PCE countries, Myanmar and Uganda, submitted

tailored for NSP funding requests during NFM3, and stakeholders reported the process to be

more efficient than the NFM2 full review. Both countries reported that information generated

during NSP development consultations fed directly into funding request processes. In

Myanmar, both processes were embedded in the CCM structures that facilitated coordination

and synergies. In Uganda, because the NSP priorities were still ‘fresh’ in the minds of those

developing the funding request, they referred to the NSP more frequently, promoting greater

alignment and harmonization, and thus improving sustainability. However, the finalization of

the disease NSPs occurred concurrently with the funding request development processes,

which created some challenges for key actors and in determining how priorities from both

processes would be harmonized. Box 3.1: Process improvements through Tailored for NSP

funding request in Myanmar.

The MoH was keen to ensure that the NSP was well integrated with a wider national health

strategic plan and focused on the overall objective of universal health coverage (UHC). They

therefore worked hard to make diverse stakeholder participation more meaningful through

the Tailored for NSP approach: the CCM Secretariat was better embedded in the MoH and

shared information widely on timelines for NSP and funding request development, well ahead

of the actual process; UN agencies facilitated community networks’ engagement, including on

matching funds and community system strengthening; and a smaller, more strategic working

group led the process, operating on a tighter, more compressed timeline.

However, NFM3 full review processes were not always more efficient, compared to ‘lighter

touch’ processes for NFM2. Three PCE countries—DRC, Mozambique and Sudan— moved from

‘lighter touch’ approaches (e.g., program continuation and tailored review) in NFM2 to full review

applications in NFM3. In DRC, stakeholders regarded the 2017 program continuation and tailored

review processes as being restricted because interventions were predetermined and, as such,

they preferred the NFM3 Full Review process, which gave them greater latitude to propose new

interventions and strategies based on data, context and NFM2 lessons learned. In Mozambique,

the NFM3 process allowed for building on a recent NSP mid-term review, to incorporate its

findings into the new NSP and funding request. On the other hand, Sudan reported the 2020

process to be significantly more burdensome than their program continuation application in

2017, due to delays in developing the NSP, which further interrupted the funding request

submission.

Compared to NFM2, the NFM3 process benefitted from greater inclusivity, transparency

and country ownership during funding request development, but not during grant making

where key decisions were often made. CCMs were reported to be smaller, more informed and

organized, and with better coordinated technical working groups across Sudan, Myanmar,

Guatemala and Mozambique, mainly due to better government leadership and wider

participation. Sudan and Myanmar reported a reduced role needed by UN agencies as government

stakeholders showed greater leadership. For the early stages of the funding request development

process, engagement and ownership by national stakeholders extended beyond the usual

Ministry of Health program leads, including Ministries of Finance (Mozambique, Uganda),

Education and Gender Ministries (Uganda), subnational or provincial stakeholders (Cambodia,

DRC, Mozambique, Myanmar), and civil society organizations (CSOs) and KVP representatives

(DRC, Senegal, Guatemala, Mozambique), suggesting a shift toward greater integration of the

grants across national health budget processes and health systems, compared to NFM2.

However, later on in the process, (i.e., during budget allocation and priority setting) stakeholders

in most countries reported lower transparency for crucial decisions. For example, in Guatemala,

although participation in early meetings was wide, final prioritization and budget allocation

decisions were made by the PR and MoH and did not include KVP representatives. CTs also

appeared to exert a strong influence during the latter stages of the funding request process, with

countries reporting significant pressure to absorb Global Fund priorities into grants. This was

also a finding of the 2017/2018 PCE Synthesis Report.(9)

A number of KVP representatives reported feeling more included in NFM3 funding request

processes than in NFM2, in some cases helped by having gained experience from previous

processes and support to build their capacity. In DRC, KVP representatives reported that their

earlier participation in the National Program Review in 2019 strengthened subsequent

contributions to the funding request process. In Uganda, a KVP consortium organized separate

meetings and a system of email inputs which assisted a much wider group to participate than

previously, as well as technical assistance from CRG SI to civil society actors involved in the

writing process to help better articulate their priorities. Other countries where KVP

representatives reported better participation included Guatemala, Myanmar and Senegal. Uganda

and Myanmar, with Tailored for NSP funding requests, reported increased participation by KVPs

across both NSPs and the funding request, with potential implications for the design of more

sustainable and effective responses to the diseases.

Irrespective of differentiated application approaches, COVID-19 changed the way the

funding request and grant making processes were managed, with both positive and

negative implications. In response to COVID-19-related restrictions, many countries conducted

funding request and grant making meetings online, which stakeholders in some countries

reported as increasing transparency and participation by a wider range of organizations. For

example, in Mozambique, an online platform enhanced transparency compared to NFM2, and the

CCM used online surveys to achieve greater consensus. Based on lessons learned in the

development of the C19RM funding request in virtual engagement of youth across regions,

Uganda’s CCM is considering the continued use of virtual consultations to increase targeted

constituency engagement going forward. However, these approaches depend on stakeholders

having good access to internet connections, which was not always the case.

The process of applying for matching funds improved for NFM3 compared to NFM2. As

noted in earlier PCE reports, in many PCE countries, the NFM2 separate application processes for

matching funds led to their budgets not being aligned to other grant implementation cycles. For

NFM3, stakeholders reported significant efficiencies from integrating matching funds processes

within the main grant applications. As explored below, matching funds for NFM3 (as for NFM2)

also appear to be helping to ensure that Global Fund strategic priority areas are addressed within

country grants, with some countries even exceeding the match requirement (for example, 2:1

matching for Uganda’s AGYW investments and marginal increase over requirements for AGYW in

Mozambique).

TRP recommendations (made both on NFM2 and NFM3 funding requests) informed NFM3

grant designs, with particular implications for HRG-Equity and RSSH related investments.

For example, Sudan in NFM3 is investing in strengthening HMIS data; prioritizing programs to

reach Internally displaced people, refugees and nomadic populations in remote states; addressing

acute gender barriers in these groups; and expanding investment in Community health

workers—all areas the TRP recommended during NFM2. In Mozambique, the NFM2 comments

from the TRP recommended increased coverage for services targeting FSWs. This was responded

to in NFM3 by increasing the performance framework target for the proportion of FSW reached

with prevention services from 13% by 2020 to 46% (67% in total including PEPFAR support) by

2023.

However, during NFM3, the TRP has again commented that coverage targets for FSW are

insufficient to reach epidemic control. In DRC, similar to comments provided in 2017, the TRP

again noted a lack of detail in the NFM3 HIV/TB funding request on differentiated HIV testing

strategies for KVPs. Although the applicant proposed numerous strategies such as HIV self-testing

at the community level, inadequate detail was included on other potential high-impact strategies

(e.g., index testing, online recruitment, and HIV case analysis from Enhanced Peer Outreach

Approaches). In response, the applicant provided a robust response with details regarding

additional high-impact strategies that will be implemented. In Uganda, there were no

recommendations related to CSS in the NFM2 request, but in NFM3 the applicants have been

responsive to a TRP recommendation to shift institutional capacity building, planning and

leadership development from the PAAR to the main allocation, which increased the RSSH CSS

allocation by 15%.

Box 3.2: TRP comments on the Myanmar 2020 funding request call for a stronger

evidence base on PWIDs to guide NFM3. During NFM2, overall HIV grant performance was

generally on track with the majority of grant coverage targets for KVPs being overachieved,

except for PWID. Despite a grant revision that significantly increased resources for PWID during

NFM2, absorption of PWID interventions addressing stigma, discrimination and violence, and

community empowerment was weak and the program achieved relatively low coverage. TRP

comments in both 2017 and 2020 highlighted the need for better evidence in relation to PWID

service coverage, access to methadone maintenance treatment and linkage to care. In response,

in 2020, the Myanmar CT requested the PCE Myanmar CEP to assess these issues to inform the

NFM3 planned expansion of PWID interventions. Findings were presented to a large group of

national stakeholders in November 2020, at an all-day meeting dedicated to the topic. As a result,

under the NFM3 grant, allocation to human rights and gender interventions has increased from

23% to 32% of the grant, including specific investments in strengthening community systems,

and resources for interventions specifically designed to address human rights barriers for PWID

have doubled from US$0.8 to US$1.6m under NFM3.

Key message 8: NFM3 funding requests included significantly larger budgets and focus on

some but not all of the areas where a change in trajectory is needed to meet the Global

Fund Strategic Objectives, largely as a result of the overall increase in country allocations.

We note a decrease in the denominator (from 97,712 in NFM2 to 86,000 in NFM3), which reflects the FSW size

estimates in the districts where the Global Fund grants are operating and is important to interpreting the scale of the

increase in the percentage of FSW targeted. The target may be subject to change in the final performance framework.

The successful Sixth Replenishment alongside a commitment to ‘do things differently’

offered an important opportunity to ‘change the trajectory’ in NFM3. The Global Fund’s 2019

investment case, used as the basis for the Sixth Replenishment to fund NFM3 grants, made a

compelling case to ‘do things differently’ in order to meet its Strategic Objectives.(10,11)

Specifically, it called for greater innovation, collaboration and effective execution, with a

particular emphasis in HIV on scaling up effective prevention to KVPs and AGYW, and significantly

more investment in overcoming HRG-related barriers to accessing health services. For TB, the

investment case called for expansion in both case finding and treatment of drug-sensitive and

MDR-TB cases, and for malaria, it called for expansion in the distribution of bed nets alongside

interventions to ensure they are used, as well as in testing and treatment. Lastly, it called for a

scaling up of investments to build RSSH. In addition, a series of applicant resources (12), including

information notes on HIV, TB, malaria and RSSH, and technical briefs on key areas of the Strategy

(human rights, gender equity, value for money, etc.), were updated to support countries in

operationalizing priorities as articulated in the Investment Case.

The 2019 Global Fund replenishment led to increases in total NFM3 allocations for all PCE

countries. As per the indicative program splits provided by the Global Fund (Figure 13), more

than half (55%) of the increased funding available in NFM3 is intended for HIV, with 35% for

malaria, and 10% for TB, with some variation by country. For example:

● Cambodia: 100% of the additional funding available in NFM3 is intended for malaria.

● Uganda: 63% of the additional funding available in NFM3 is intended for malaria.

● Mozambique: 83% of the additional funding available in NFM3 intended for HIV.

● Myanmar: 68% of the additional funding available in NFM3 is intended for TB, with a 1%

decline in funding for HIV.

Figure 13: PCE country allocations with indicative program split

Source: Global Fund detailed budgets

Data accessed through the Global Fund Data Service Allocations dataset.(13) Accessed on 25 November 2020. Actual

funding request budgets for the RAI3E included for Cambodia and Myanmar.

HRG-Equity

Key Message 9: PCE countries show evidence of NFM3 funding requests being designed

with explicitly more focus than in NFM2 on improving equitable access to health services

and allocating resources to intervention approaches that are known to contribute to

greater programmatic sustainability.

Nearly all PCE countries increased investments (both in absolute terms and as a

proportion of their NFM3 budgets) in prevention and KVPs compared to NFM2 budgets

(Figure 14). Overall, HIV prevention budgets increased in Cambodia, Guatemala, Mozambique,

Myanmar and Uganda (Annex Figure 5.1). In Cambodia and Myanmar, this was made possible by

governments taking on increasing responsibility for financing treatment costs, related to the STC

Policy, which freed up Global Fund resources for other purposes.

In DRC, Guatemala,

Mozambique and Uganda, the increase in budget for prevention emerged from the increased

NFM3 HIV allocation rather than by sacrificing other aspects of the grant (Annex Figure 5.1). Only

Senegal saw relatively small or no increases in KVP or HRG-related investments, as the planned

responses for KVPs in the HIV program were not considered sufficiently comprehensive by the

TRP or ambitious to achieve proposed 2022 targets, even though KVP targets increased between

NFM2 and NFM3. Smaller gains were notable for programming to address human rights barriers

in countries eligible for crosscutting human rights matching funds, including DRC, Mozambique,

Senegal and Uganda. Global Fund business model drivers of expansion in equity-related

investments, including the overall larger allocations, matching funds incentives, and improved

data sources to guide target setting, are discussed below. Likewise, for TB, as well as general

increases in funding for case finding (supported through matching funds), TB care and prevention

and MDR-TB, five PCE countries included TB-specific human rights-related investments in NFM3

(Cambodia, DRC, Mozambique, Myanmar and Senegal).

Box 3.3: Mozambique’s substantial increase in equity-related investments in NFM3 as a

result of increased overall allocation. The budget for activities to address HRG-Equity-related

barriers in the NFM3 HIV/TB funding request (US$78m) is significantly higher than under NFM2

(US$46m at funding request; US$34m at grant award; and US$40m as per the latest official

budget revision), reflecting the huge increase in the overall NFM3 allocation. The NFM3 budget

includes US$15m for human-rights-related investments, US$23m for wider KVP investments

and US$40m for other equity-related investments. Similarly, reflecting concerns around

increased HIV incidence in Mozambique, the prevention budget, excluding PMTCT, more than

doubled, from US$18m in the NFM2 funding request to US$46m in the NFM3 funding request,

most notably for prevention among AGYW: from US$6m in the NFM2 funding request to

US$14m through NFM2 grant implementation and to US$20m in the NFM3 funding request.

In Cambodia for example, the government commitment to ARV procurement has increased from US$9m under NFM2

to US$20m under NFM3.

Figure 14: Changing budgets for HRG-Equity-related investments across NFM2 and NFM3.

Source: Global Fund detailed budgets

In some cases, efficiency and/or effectiveness considerations appear to have taken

precedence over equity considerations in the design of NFM3 grants. For example, compared

to NFM2, NFM3 grants cut subsidies for linkage to care (Guatemala) and patient living support

(Cambodia, Myanmar)—both critical to ensuring that the poorest can afford to access services.

Cambodia and Myanmar cut resources for PLHIV living support in order to prioritize more

efficiently targeted KVP HIV testing and increased budget for prevention. Guatemala reduced the

budget for travel subsidies and sub-recipient peer promoters due to concerns about the

effectiveness of promoters in identifying new HIV cases during NFM2. Although the Global Fund

issued new guidance on VfM to inform grant design, stakeholders in some countries (Cambodia,

Sudan) reported that VfM guidance had mainly been used by in-country consultant drafting teams

rather than reflecting improved discussion on VfM and/or equity among national stakeholders.

Box 3.4: Concerns about perceived inefficiency of peer promoters in Guatemala during

NFM2 seemed to outweigh equity considerations in NFM3. During the NFM3 funding request

development, updated KVP prevalence data were unavailable due to delays, which was a barrier

to improved intervention targeting. With limited data on KVPs, the PR relied on data from a

report, commissioned by the CT, on the productivity of peer promotors in NFM2 which found

low productivity in detecting and linking new cases to care. These findings informed a decision

by the PR to cut the budget for promotors in NFM3 and it is unclear whether potential

consequences on equitable access by key populations were given equal weight to efficiency

concerns.

Figure notes: *Revision is the most recent official budget revision. Percentages show the share of total grant budgets

that HRG-Equity makes up. Sudan is excluded from the figure, as the malaria grant did not include HRG-Equity

investments. Guatemala data include the HIV grant only. NFM2 funding requests (FR) in Senegal and DRC do not include

Program Continuation, specifically malaria grants in DRC and HIV and malaria in Senegal. In NFM2, due to the delayed

incorporation of catalytic matching funds after grants were approved, catalytic funds are reflected in the most recent

revision, except in Myanmar where they are included in the NFM2 funding request.

In response to concerns with efficiency, and given the lessons learned during NFM2 related to SR

selection and contracting issues that delayed implementation start-up, several countries are

retaining well performing SRs into NFM3 (Cambodia, DRC, Uganda), which will help promote

‘implementation readiness’ of approved grants—particularly for equity-related investments

carried out predominantly by SRs. In line with the Secretariat’s new guidance on preparing for

implementation ready grants, in early 2021 LFAs are conducting verification of implementation

readiness to quickly assess whether grant implementation is on track and the reasons why

(recognizing that COVID-19 is likely to have impacted plans around implementation readiness).

NFM3 grants have not substantially changed their orientation toward human rights,

gender and other elements of equity that would promote more sustainable impact on

services access and disease outcomes. Importantly, a disconnect remains between grant

‘equity’ indicators (which focus largely on budgetary contributions to human rights and KVP

interventions in addition to being heavily weighted toward HIV-relevant indicators) and wider

understanding of inequality in access to health services or health outcomes, which could better

inform an understanding of the equitable distribution of grant investments. A stronger

consideration for geographic accessibility was, however, evident in several countries. For

example, Senegal will expand diagnostic tools during NFM3 (GeneXpert, PCR, microscopy) to

address a lack of access in some high-burden areas. In Mozambique, malaria modeling and

surveillance results are being used to target higher-burden areas (see Box 3.5). In Sudan, the

malaria program has expanded to reach a wider number of provinces, many of which have large

internally displaced populations and refugees that were previously not reached.

Box 3.5: Mozambique’s VfM considerations in prioritizing malaria investments. During

NFM2, where the Agente Polivalente Elementars (APE) community health worker malaria

program operated, it performed well against mortality performance metrics. However, APE

distribution was not determined by malaria burden of disease, with some geographic areas

being under-resourced, thus limiting its overall impact. Under NFM3, the grant is expanding

community diagnosis and treatment for malaria, and community awareness through

conducting social and behavioral change communication activities designed to encourage

greater impact as well as continued provision of supply kits to the APEs for diagnosis and

treatment. NFM3 responds to new malaria modeling and surveillance results, which revealed

the need to target high-burden areas with more effective interventions, thereby prioritizing

equity as well as efficiency.

Several PCE countries used better-quality and/or more recent data on KVPs during NFM3

compared to NFM2, which enabled grants to set up new interventions to target KVPs more

precisely or widen the geographical distribution of places that KVPs would receive

services. However, ongoing concerns on the quality of data (particularly the accuracy of

KVP population size estimates) continue to constrain allocative efficiency. In some PCE

countries, the NFM3 funding request development process was more data-driven than that of

NFM2, largely because new data, particularly on KVPs, had become available. For example, based

on newly available data in Uganda and Mozambique, NFM3 grants are significantly expanding HIV

prevention programming for AGYW to include new geographies and increased overall coverage

targets. In Uganda, a baseline AGYW assessment completed during NFM2 informed the NFM3

design, including a strategic shift toward scale-up to achieve the ‘saturation’ required to reduce

incidence among AGYW, coupled with stronger integration of sexual and reproductive health and

HIV services for adolescents, both of which contributed to incorporation of US$59m for AGYW in

the Prioritized Above Allocation Request (PAAR).

In addition, the Essential Data Tables (EDT) (a new tool introduced by the Secretariat to improve

the funding request process by providing applicants with pre-populated and up-to-date data

related to demographics, the three diseases and other relevant crosscutting information)

informed NFM3 planning. DRC, Senegal and Myanmar reported using the new EDT to inform

NFM3 planning. Stakeholders in DRC considered the EDTs to contribute to a more efficient

process by reducing the time required to consolidate various data sources. In Senegal, although

stakeholders used the EDTs, they continued to question the accuracy of KVP estimates. In

Guatemala, implementation delays for HIV prevalence studies in NFM2 meant that those studies

were not available to inform NFM3 design. Both Guatemala and Senegal included investments in

NFM3 to improve KVP estimates.

Box 3.6: Using data to inform prioritization of human rights and gender investments in

DRC. NFM3 grants will prioritize equity through the sizable scale-up of activities targeting KVPs

and the expansion of interventions to reduce HRG barriers to services. DRC’s indicative HIV

allocation increased by 42% in NFM2, from US$123m to US$174m. Drawing upon updated KVP

size estimates that revealed a six times larger KVP population than previous estimates, in

consultation between the CT, country stakeholders, and technical partners, the PR decided to

intensify prevention activities that have historically been under-prioritized. NFM3 HIV testing

targets for all KVP categories are significantly higher than NFM2, which will address the current

low percentage of people living with HIV that know their status. The TRP review of the 2020

funding request noted strengthened and expanded HRG interventions compared to previous

rounds. Key facilitators included the use of data to define strategies for addressing HR barriers;

the Global Fund-supported Breaking Down Barriers initiative that produced a baseline

assessment and convened stakeholder consultations leading to the development of a five-year

costed HRG National Plan with priority activities; and availability of catalytic matching funds.

RSSH

Key Message 10: Most PCE countries increased the overall allocation to RSSH in NFM3,

although, compared to NFM2, a greater proportion of these investments are designed to

support rather than strengthen health systems. As such, it is unclear how the NFM3 grants

are intended to ‘change the trajectory’ for the achievement of SO2, which is intended to

increase strengthening investments and enhance RSSH.

The budget for RSSH modules increased significantly in NFM3 in several PCE countries

(Cambodia, Mozambique, Senegal, Uganda), while in other countries the RSSH budget

remained relatively stable (Guatemala) or declined slightly compared to NFM2 approved

budgets (DRC, Myanmar, Sudan). However, only Cambodia, Guatemala and Myanmar saw

increases in strengthening investments from NFM2 to NFM3 (Figure 15), and they were

minor.

In most PCE countries, the proportion directed to strengthening activities actually

decreased from NFM2 to NFM3. While a higher allocation to supportive investments may be

appropriate in some countries (e.g., Uganda, Mozambique, DRC) given their place on the

development continuum, this is not the case in other countries that are closer to transition (e.g.,

Cambodia, Guatemala).

As such, evidence suggests that the Global Fund’s RSSH guidance “to shift from a focus on

short-term, input-focused support...towards more strategic investments...that build capacity

and lead to sustainable results” is not being systematically operationalized.(1, p. 5) This is

partially explained by the shorter (three-year) funding period, lack of domestic and donor

funding sources for RSSH (other than the Global Fund), use of funds for commodities, and the

persisting vertical nature of the three disease programs. It is worth emphasizing that despite the

Building from the “2S“ framework proposed by Chee (2013) (3) and the “4S” work in the TRP’s RSSH Review (2018)

(4), the PCE developed a simplified coding “2S” application to analyze support and strengthening activities. See Annex

4 for protocol guidance. The 2S analysis compares the final NFM2 approved budgets with the NFM3 funding request

budgets (because at the time the analysis was conducted the NFM3 grant making budgets were unavailable).

stated desire by the Global Fund to invest in more strategic strengthening interventions, many

PCE countries still require some level of investment in systems support (indeed, inputs-oriented

investments may be a precursor to some longer term strengthening efforts). If the Global Fund

truly intends its investments to be primarily strengthening RSSH, rather than supporting disease

program functions, PRs and country-level program managers require more information for how

to distinguish support and strengthening investments and also how to operationalize the

guidance to invest more in strengthening activities.

Figure 15. Comparison of RSSH budget between approved grants (NFM2) and funding request

budgets (NFM3), including shifts in proportion for supporting vs. strengthening activities.

Source: Global Fund detailed budgets

Note: Circles are sized according to overall RSSH budget size, as indicated by key with grey bars to the right.

In some countries, NFM3 RSSH investments are designed building on progress made

during NFM2, especially in HMIS/M&E. In DRC, Mozambique, Myanmar, Senegal and Sudan,

work in NFM2 to develop, roll out and expand DHIS2 (e.g., through an eHealth platform in

Myanmar) intends to be expanded upon in NFM3, where the focus is more oriented toward

expanding routine data collection, assessing data quality and training of technicians to improve

its application. In Mozambique, plans include a shift in PSM/HPM investments from support for

warehouse infrastructure and commodity storage capacity in NFM2 toward in-country

distribution and regulatory/QA support to combat counterfeit or low-quality drugs in NFM3. In

Sudan, investments in laboratory systems also appear to have evolved from infrastructure and

rehabilitation costs in NFM2 to improving the efficiency and quality of laboratory functions in

NFM3.

Box 3.7: Strengthening HMIS and digital health investments in DRC. In NFM3, DRC’s

investments in digital health, although smaller than in NFM2, received the largest portion of the

RSSH budget (the HMIS/M&E module represents 56% of the total RSSH budget). While DRC’s 2S

analysis showed an overall decrease in strengthening investments from 42% to 35% between

the NFM2 approved budget and NFM3 funding request, the HMIS/M&E module was the

exception where strengthening investments increased from 50% to 55%. In part, this is

explained by NFM3 digital health interventions that build upon lessons learned during NFM2.

For example, NFM3 grants increased focus on improving HMIS data quality and data use. While

NFM2 investments were successful in improving systems integration and reporting by all disease

programs in DHIS2 (achieving greater than 90% data completeness), gaps remain in data quality,

reporting timeliness and data use for program management that will be addressed during NFM3.

In addition, DRC also aims to enhance coordination between public and private sectors in NFM3

with integration of private sector data in DHIS2 as a key priority. Related investments include

developing official guidelines and standard operating procedures for how private health

establishments will be integrated into national policy and information systems, including at the

provincial level, which will further promote data system sustainability.

Box 3.8: Sustainability considerations in strengthening HMIS in Guatemala. Despite a large

investment in NFM2 to deploy DHIS2 to facilitate monitoring and reporting by the non-

governmental PR, and encouragement by the CT, TRP and others to build upon this, the PCE

found that certain stakeholders were against adoption of open-source technologies such as

DHIS2 and favored the development a new informational system for the national HIV program

using an Oracle platform. However, recently, the Minister of Health has stated an interest in

scaling up DHIS2 for the whole MoH. Many HIV program stakeholders, including the PR, were

unaware of the Minister’s interest until the end of 2020. While greater country ownership and

political will is indeed positive, these more recent developments could slow the Global Fund

HMIS investments as they will need to be aligned to the still nascent strategy of the MoH.

Considering that malaria and TB are entering transition during NFM3, delays to HMIS

strengthening presents risks.

Most PCE grants did not appear to use the NFM3 funding request process to link RSSH

investments more strategically with sustainability plans. In PCE countries, in addition to

findings above on the type of RSSH investments, few countries appeared to have prioritized

alignment of funding requests and NSPs with wider health plans, and transition plans did not

appear to be used systematically to guide domestic RSSH investments. In addition, few PCE

countries reported successful grant investments in structural or institutional shifts toward a

more sustainable approach to addressing their disease epidemics, as is confirmed in other

assessments of policy strength, an exception being Cambodia, where a 2019 proclamation aimed

to facilitate government contracting with NGOs.(16) PCE evidence suggests the NFM3 funding

request process may therefore have missed an opportunity to move national disease programs

toward eventual transition away from dependence on external funds. This finding aligns with

sustainability challenges raised by the TRP, many of which overlap with RSSH: 1) limited planning

of domestic resources for pooled procurement and integrated service delivery across programs

(Cambodia, DRC, and Uganda), for maintaining KVP outreach and programming (Guatemala), and

to meet financing gaps for NSP (Cambodia); 2) gaps in capacity of national entities to identify

efficiencies and cost savings (DRC, Guatemala, Mozambique, Myanmar); and 3) lack of M&E for

sustainability roadmaps (Cambodia, Myanmar), Health Financing Strategies (DRC, Mozambique),

and other program-specific sustainability plans (Cambodia, Uganda).

Box 3.9: Mixed progress on sustainability in Myanmar. During NFM2, the national HIV

program introduced significant policy reform to increase equitable access to treatment and

prevention services for KVPs, including legal reforms to reduce punitive measures for KVPs;

shifting the National Drug Control Policy toward a public health approach to improve PWID

access to harm-reduction services; launching a Prison SOP in collaboration with Ministry of

Home Affairs (MoHA) to improve HIV services in prisons; initiating guidelines for new

combination of prevention interventions for KVPs; and revising township classification for

HIV programming based on HIV burden to ensure key populations in remote and hard-to-

reach areas are not left behind. The Global Fund is the major financier of all these efforts, and

the NFM2 grant prioritized treatment and prevention service coverage in high-burden areas.

However, despite progress, root causes of the barriers remain unaddressed: armed conflicts

and security situations in Kachin, Shan and Rakhine continue to prevent the full

implementation of TB and HIV programs; and poverty, external and internal migration, and

language barriers in ethnic minority states continue to pose as barriers to accessing services.

Advocacy efforts for protection of violence against women have become visible in recent

years, but no legal framework exists to prevent and protect from intimate partner violence.

TRP comments in both 2017 and 2020 highlighted limited progress in building long-term

program sustainability beyond the grant period, particularly human resources for health and

community system strengthening and contracting.

In some countries, NFM3 grants are shifting RSSH intervention approaches, with greater

emphasis on community systems strengthening for improving access to and quality of

service delivery. Several countries substantially expanded CSS investment under NFM3,

including DRC, Mozambique, Myanmar, Senegal and Uganda (in line with broader NFM2 TRP

observations).(17) Both Senegal and Uganda included investment in community-level data

collection and reporting into DHIS2. Some countries are building integration and equity

considerations into RSSH investment design. In Senegal, for example, addressing laboratory

services gaps will help improve overall diagnostic testing service availability to KVPs. In DRC, the

NFM3 funding request includes stronger emphasis on integrating across disease programs,

including greater support for community-based organizations involved in comprehensive health

prevention and promotion; integrated supervision tools for the three diseases and other maternal

and child health interventions; and capacity building for provincial health authorities. In

Cambodia, most CSS investments coded as ‘strengthening’ in NFM2 were outsourced to a CSO

partner to coordinate KVP meetings. Stakeholders reported limited added value for this as a

primary activity and, although it was retained in NFM3, it was moved from the RSSH CSS module

and re-assigned to the ‘removing human rights barriers’ module.

Box 3.10: Investing in stronger community systems in Uganda. The RSSH allocation for the

CSS module increased seven-fold from the NFM2-approved grants (US$830K) to the NFM3

approved grants (US$6.9m), driven by several factors including increased civil society advocacy

and active engagement in the funding request process, as well as previous PCE findings

highlighting limited Global Fund investment in CSS. During NFM3 grant making, an additional

US$908K was added in response to a TRP recommendation to move the “institutional capacity

building, planning and leadership development” intervention from the PAAR to the main grant.

However, given that CSS investments during NFM2 have been extremely delayed in

implementation (absorption <30% as of June 2020), PRs will need to ensure more effective

grant start-up to avoid delays. The 2S analysis of the CSS RSSH module suggests a marginal

improvement toward increased strengthening investments, from 32% in NFM2 to 40% in

NFM3. An infusion of US$3.0m through matching funds for community health data science will

support strengthening community reporting, including through digitization efforts

interoperable with DHIS2 systems, thereby promoting stronger use of data for decision-making

and programmatic sustainability.

Several countries show governance adaptations to improve coordination and

implementation of crosscutting RSSH investments. In Senegal, for example, grant

implementation arrangements are structured so that ownership of RSSH investments is more

centralized under a single government PR and a civil society PR implementing community-based

activities. Similarly, in Uganda, a stronger coordination structure with the government PR

providing oversight and implementation of crosscutting RSSH investments, while the civil society

PR manages and coordinates CSS interventions was developed. Both Cambodia and DRC have

applied for stand-alone RSSH grants in NFM3. In DRC, this was proposed by the CCM to deliver

more integrated RSSH interventions and elevate health systems issues to the Secretary General

and MoH, who will be managing the grant. In Cambodia, RSSH resources come from the regional

malaria grant (RAI) and, in order to integrate it better with other disease grants, the CCM decided

to continue implementation through the MoH Lead Implementing Team, but have the grant

managed by the Ministry of Economy and Finance rather than UNOPS, which is anticipated to

improve governance and coordination.

Despite extensive new guidance, most PCE NFM3 grant performance frameworks do not

appear to include many of the new RSSH coverage indicators,

suggesting that monitoring

RSSH performance and progress toward meeting SO2 will remain a challenge. The Global

Fund updated the modular framework in 2019 with extensive revisions and additions to coverage

indicators for each of the RSSH modules: expanding from 13 to 24 RSSH coverage indicators, 22

of which were newly added.

However, beyond standard HMIS and M&E module indicators,

adoption of other RSSH indicators aligned to major investment areas was infrequent in

performance frameworks submitted with funding requests (consistent with the TRP Window 2

review findings regarding an inadequate range of indicators for coverage, outcome and impact of

RSSH investments)(15) (Table 5). For instance, in Guatemala, where HMIS comprises the majority

of the RSSH investment within the HIV grant, no RSSH coverage indicators were included in the

performance framework. There does, however, appear to be more progress for CSS

investments—for instance, three countries prioritizing CSS investments (DRC, Senegal and

Uganda) included one of the two newly added CSS indicators from the modular framework.

Several funding request performance frameworks included Work Plan Tracking Measures

(WPTM) for monitoring investments in CSS (Cambodia, Uganda), laboratory strengthening

(Cambodia, Mozambique), and HMIS/M&E (Mozambique). Additional WPTMs were also

introduced during grant making, for example for monitoring integration of private sector

reporting into DHIS2 (DRC), and improvements in the comprehensiveness and quality of routine

reporting (Myanmar), among others.

Coverage indicators rarely capture aspects of system strengthening (such as data use for

decision-making) and some RSSH investment areas do not map well to the available indicators.

Beyond performance framework indicators, some countries may include complementary in-

depth RSSH assessments to measure aspects of systems strengthening and performance, which

was an approach undertaken in NFM2 for equity-related investments. Some countries included

custom RSSH indicators in performance frameworks to better fit the monitoring needs of their

RSSH investment areas and stronger opportunities to measure aspects of systems strengthening.

For example, according to stakeholders in DRC, there was a concerted effort to develop indicators

beyond output measurement (such as facilities that receive supportive supervision), but also

capture the quality of those supervision visits according to national standards and guidelines.

Following funding request submission, the TRP did not provide feedback for amending, including,

or strengthening RSSH indicators. Additional investigation is warranted to understand the

limited uptake of RSSH indicators in some countries.

The PCE has previously reported challenges in performance monitoring of Global Fund RSSH investments, wherein

NFM2 grants reported against only three RSSH coverage indicators: M&E-1: Percentage of HMIS or other routine

reporting units submitting timely reports according to national guidelines (Cambodia, Myanmar, Senegal, Sudan,

Uganda); M&E-2: Proportion of facility reports received over the reports expected during the reporting period

(Cambodia, DRC, Mozambique); and PSM-2: Percentage of health facilities with essential medicines and life-saving

commodities in stock (Senegal).

Of the 13 RSSH coverage indicators in the 2017 modular framework, 11 were discontinued and only two were

retained in the 2019 modular framework, which contains 22 new RSSH coverage indicators. All RSSH impact indicators

were removed and four new RSSH outcome indicators were included. Of the PCE countries, DRC (HSS O-6, HSS O-7,

HSS-O8, and a custom HSS outcome indicator) and Sudan (HSS O-5) are the only to incorporate RSSH outcome

indicators into NFM3 funding request performance frameworks.

Table 5. Coverage indicators in NFM3 funding request performance frameworks by RSSH module

and proportion of RSSH investment in each RSSH module, per country.

Table Notes: Percentages and color gradient represent the amount of the total country RSSH budgets each module

comprises. Indicator definitions: M&E-2a Completeness of facility reporting: Percentage of expected facility monthly

reports (for reporting period) that are actually received; M&E-2b: Timeliness of facility reporting: Percentage of

submitted facility monthly reports (for reporting period) that are received on time per the national guidelines, M&E-

4: Percentage of service delivery reports from community health workers integrated into HMIS; M&E-5: Percentage of

facilities which record and submit data using the electronic information system; PSM-3: Percentage of health facilities

providing diagnostic services with tracer items available on the day of the visit or day of reporting; PSM-4: Percentage

of health facilities with tracer medicines for the 3 diseases available on the day of the visit or day of reporting; SD-5:

Percentage of facilities that receive supportive supervision at least 1 per quarter; CSS-1: Percentage of community-

based monitoring reports presented to relevant oversight mechanisms; HSG-1: Percentage of district health

management teams or other administrative units that have developed a monitoring plan, including annual work

objectives and performance measures. Custom indicates countries included a custom indicator. WPTM = Work Plan

Tracking Measures. Myanmar and Cambodia include budget and indicators for TB/HIV grants only.

In Cambodia, the TB/HIV grant and the separate RSSH grant are now supervised by the same CT. Both grants use the

PMTCT module and both grants apply RSSH specific modules. The TB/HIV grant used three RSSH modules in NFM2

and in NFM3. The RSSH grant used three RSSH modules in NFM2 and five modules in NFM3. NFM3 grant retained the

NFM2 activity (sole CSO) under RSSH-CRS, although shifted to the Removing Human Rights Barriers module. Modules

in the stand-alone RSSH grant are implemented by separate departments within the MOH, and performance indicators

in this grant are linked only to the PMTCT module. PMTCT procurement of RDT is made via the TB/HIV grant previously

included via Treatment Care Support module but now shifted to the PMTCT module in NFM3. Meanwhile training and

related ANC activities are channeled via the PMTCT module in the RSSH grant.

Chapter 4: Discussion and conclusions

In this chapter we set out our overall conclusions in relation to how the Global Fund business

model is facilitating and impeding the achievement of Strategic Objectives across the grant cycle.

The focus is primarily on RSSH and HRG-equity, paralleling Global Fund SO2 and SO3, and

examining the degree to which business model incentives that operate through these areas

indirectly affect the achievement and acceleration of sustained impact on the three diseases

(SO1). Overall, the PCE evidence suggests that the Global Fund business model has facilitated

improvements across the grant cycle in design and implementation during these past 3-4 years.

However, these trends appear unlikely to deliver the sustained improvements in equity and/or

health system strengthening needed to achieve the Strategic Objectives and 2030 goals.

Grant Design

Conclusion 1: Improvements to the business model between NFM2 and NFM3 contributed

to more efficient and inclusive funding request processes. However, NFM3 saw limited

adoption of changes in the design of performance monitoring, particularly for HRG-equity

and RSSH.

The NFM3 funding request process was generally more efficient and benefited from changes that

meant a wider set of stakeholders were included, despite COVID-19 interruptions to the process.

The tailored to NSP and full review differentiated application approaches were viewed positively

relative to NMF2, particularly as relates to inclusion, although stakeholders reported inclusion

declined at later stages of grant making. Most PCE countries also showed evidence of increased

national ownership of Global Fund grants and disease programs, perhaps reflecting gradual

country familiarity and adaptation during the third round of NFM grants. Incorporating matching

funds within the main funding request in NFM3 improved alignment and the efficiency of the

design process, a key improvement over NFM2, as well as catalyzed increased investment for

HRG-Equity. However, despite some increases in data quality and use, particularly for KVPs,

performance frameworks, indicators and targets changed surprisingly little—particularly for

HRG-Equity and RSSH interventions. Measuring Global Fund impact on other areas of equity

beyond KVP service delivery, whether due to socioeconomic status, gender barriers or ethnic

group discrimination, remains challenging.

Conclusion 2: In NFM3, both RSSH and HRG-Equity investments rose, in many cases as a

result of overall allocation increases. An increased proportion of RSSH investment is

directed toward activities that support rather than strengthen the health system.

Many new grants include large increases in KVP HIV prevention investments but smaller

increases in reducing HRG barriers (from a lower base). Despite revised guidance and greater

emphasis in the funding request template, it remains unclear if or how VfM considerations are

systematically and holistically considered in prioritization and decision making. The funding

requests do demonstrate some evidence of growing expertise and investment in areas of the

health system (CSS, HMIS, PSM), but overall there was a lack of clear and consistent consensus on

the ultimate purpose of RSSH investments. RSSH investments continue to be owned and designed

by disease-specific stakeholders, with limited evidence of an integrated and aligned approach

within wider health planning and financing systems, which likely contributed to a tendency

toward designing supporting rather than strengthening interventions. Collectively, the PCE

country NFM3 funding requests demonstrated relatively little evidence that they were designed

specifically to promote programmatic sustainability beyond the grant horizon, even in countries

close to transition.

Grant Implementation

Conclusion 3: Implementation of NFM2 grants faced significant start-up delays and COVID-

19 interruptions. Absorption was overall weaker for RSSH and HRG-Equity interventions.

The NFM introduced a fixed implementation period compared to the previous round’s system

and, alongside the introduction of portfolio optimization, strong incentives to maximize resource

utilization within a relatively short three-year time period. The increased predictability of funds

is perceived as a positive development, although the NFM grant cycle has also had some

unintended consequences linked to Conclusion 4. The Global Fund Country Team structure is a

critical element of the business model that generally works to support grant implementation,

particularly where regular reviews and coordination meetings, tailored to the country context,

take place.

However, a number of areas of the business model were less supportive of efficient grant start-

up, including lengthy selection and contracting processes for implementers and issues with

disbursements between PRs and SRs, as well as weak coordination functions, which particularly

affected RSSH and HRG-Equity interventions.

Conclusion 4: Multiple barriers and challenges exist for undertaking revisions to the scope

and/or scale of grants mid-cycle, such as in response to new evidence or emerging

performance issues.

Incentives acting on grant implementers to achieve high levels of absorption, which is rigorously

measured and reported on, are relatively strong. In contrast, incentives for grant managers to

undertake substantial mid-cycle program revisions to the grant scope (objectives or key

interventions) or scale (targets) to maximize impact are relatively weak. Firstly, the

administrative requirements for doing so are burdensome; and secondly, grant-specific

performance monitoring data to guide revision decision making is fairly limited.

As a result, two unintended consequences emerged during NFM2:

● decisions around grant revisions appear driven by the short implementation cycle and the

associated need to maximize absorption, and instead PRs and Country Teams tend to rely

on multiple, smaller budget revisions to influence implementation and for financial

management to maximize absorption; and

● where new survey and evaluation data emerged, grant revisions to scope or scale appear to

have been deferred to the NFM3 funding request cycle, rather than undergoing burdensome

but innovative revisions.

Revisions were often used to shift budgets to later in the grant cycle, having the effect of making

absorption appear higher in earlier years. Overall, in PCE countries, the cumulative effect was

small net increases allocated to HRG-Equity interventions, compared to grant awards, but a more

mixed picture for RSSH with decreases in some countries and increases in others. It remains to

be seen how these shifts will affect Year 3 budgets and absorption, in the context of COVID-19.

Chapter 5: Strategic recommendations/considerations

The purpose of these recommendations is to engage in a dialogue with the TERG and the

Secretariat on ways to respond to the conclusions in Chapter 4.

Recommendation 1: Improve grant-specific performance monitoring to inform

implementation decisions.

● Establish routine grant review processes at the country level with a quality improvement

lens, emphasizing grant-specific performance data and drawing on emerging evidence and

data to better inform revisions that maximize impact. (PRs, Grant Management Division

including Country Teams)

● Implement proposed reforms of the grant rating system to reflect both grant-specific

performance and contribution of Global Fund grants to national program performance.

Additionally, this should draw upon qualitative inputs, including expertise of the CCM, LFA,

Country Team and wider Secretariat. (Grant Management Division, Strategy Committee,

Board)

● Based on the revised grant rating system, the Secretariat should also develop a set of

indicative options to demonstrate how good and poor performance could be responded to,

and a framework for deciding when and how to introduce these measures in different

contexts and circumstances (Grant Management Division, Strategy Committee, Board).

● Strengthen the use of revised RSSH indicators to address delayed implementation and

potential deprioritization throughout grant implementation. (PRs, Grant Management

Division including Country Teams)

Recommendation 2: Build in more flexibility and responsiveness in implementation by

simplifying grant revision processes to encourage their use throughout the grant cycle.

● Consider flexibilities and streamlining of material program revision process to

encourage/reward earlier introduction of innovative programming that maximizes impact

and limits non-strategic budgetary shifts to later in the 3-year grant cycle. (Secretariat)

● Introduce flexibilities to PR and SR contractual arrangements and performance frameworks

that can be used to introduce mid-term changes as required. (PRs, Grant Management

Division)

● Through the Secretariat’s planned grant revision review (mid-2021), examine how countries

could strengthen data-driven revision decisions (thereby avoiding the over-reliance on

financial data to guide revision decisions), in line with establishing a more streamlined,

flexible process for program revision. (Secretariat)

Recommendation 3: In order to reduce gaps between policy guidance and grant design,

improve communication around how to invest more strategically in RSSH, including CSS.

● In the next Strategy, the Global Fund board in collaboration with the Secretariat should clarify

their position on whether the primary objective of RSSH is to support the three disease

programs or to invest more holistically in health systems strengthening. (Board, Secretariat

RSSH team)

● Clarify specific Global Fund RSSH priority areas and what strengthening as opposed to

supportive investment would look like for these, including specific purpose, indicators and

targets in performance frameworks. (Secretariat RSSH team, Country Teams)

● To facilitate integration and strengthening RSSH, ensure proper engagement and ownership

from health system planning experts and leaders to support health sector-wide programming

decisions, including alignment of grant design and sustainable financing within wider

national health, health system and UHC policy context, and the timelines associated with

broader strengthening efforts. (PRs, Country Teams)

Recommendation 4: In order to improve grant contribution to equity and SO3, explicitly

promote grant investments in these areas, including through more direct measurement of

the drivers of inequity and of outcomes of human rights and gender investments.

● Invest more in data and data use, including up-to-date KVP surveys as well as other data

sources that shed light on socio-economic, gender, geographical and ethnic differences in

disease burden and access to services that grants are aiming to contribute to. (Country Teams,

national stakeholders)

● Ensure performance frameworks incorporate existing data including on human rights and

political commitment as well as disease burden and service access amongst different

population groups and use this data effectively to monitor grant contribution to both SO3 and

SO1 or disease impact. (Country Teams, national stakeholders)

● Recognizing the success of strategic initiatives and/or matching funds in incentivizing grant

investments in reducing equity, human rights and gender related barriers to accessing

services, prioritize scaling up across the portfolio and incentivizing such investments through

mainstream grant management operations. This should include explicit efforts to improve

implementation and where necessary, timely revisions to maximize grant contribution to

reducing barriers to care and disease impact. (Grant Management Division, Strategic

Initiatives team)

References

1. The Global Fund. Building Resilient and Sustainable Systems for Health (RSSH)

Information Note [Internet]. 2019. Available from:

https://www.theglobalfund.org/media/4759/core_resilientsustainablesystemsforhealth_infon

ote_en.pdf

2. The Global Fund. Eligibility & Allocations Archive [Internet]. [cited 2021 Jan 22]. Available

from: https://www.theglobalfund.org/en/archive/eligibility-allocations/

3. Chee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system

support and health system strengthening is needed. Int J Health Plann Manage. 2013;28(1):85–

94.

4. Technical Review Panel. Report on RSSH Investments in the 2017-2019 Funding Cycle

[Internet]. The Global Fund; 2018. Available from:

https://www.theglobalfund.org/media/8093/trp_rssh2017-2019fundingcycle_report_en.pdf

5. The Global Fund. “Funding Approved for COVID-19 Response” database. Flexibilities data

(12/21/20) and C19RM data (12/24/20). [Internet]. [cited 2021 Jan 13]. Available from:

https://www.theglobalfund.org/en/covid-19/

6. The Global Fund. Operational Policy Manual, Issue 2.27 [Internet]. 2020. Available from:

https://www.theglobalfund.org/media/3266/core_operationalpolicy_manual_en.pdf

7. EHG, ITAD, UCSF. Strategic Review 2020 Final Report: Vol 1 [Internet]. 2020. Available

from: https://www.theglobalfund.org/media/10498/terg_strategicreview2020_report_en.pdf

8. EHG, ITAD, UCSF, IHME, PATH, Johns Hopkins University, Bloomberg School of Public

Health. Global Fund Prospective Country Evaluation: 2019 Synthesis Report. 2019 Feb.

9. EHG, ITAD, UCSF I. Global Fund Prospective Country Evaluation: 2018 Synthesis Report.

2018.

10. The Global Fund. The Global Fund Investment Case 2019, Presented by Peter Sands

[Internet]. 2019 [cited 2021 Jan 22]. Available from:

https://www.youtube.com/watch?app=desktop&v=ieTyzTvDG38

11. Step up the fight: Investment Case, Sixth Replenishment 2019 [Internet]. Geneva,

Switzerland: The Global Fund; 2019. Available from:

https://www.theglobalfund.org/media/8279/publication_sixthreplenishmentinvestmentcase_r

eport_en.pdf

12. The Global Fund. Applicant Guidance [Internet]. 2019 [cited 2021 Jan 22]. Available from:

/en/funding-model/applying/resources/

13. Data Service - The Global Fund to Fight AIDS, Tuberculosis and Malaria [Internet]. Data

Service. [cited 2020 Nov 25]. Available from: http://data-service.theglobalfund.org

14. The Global Fund. TRP Lessons Learned from Review Window 1 of the 2020-2022 Funding

Cycle [Internet]. 2020. Available from: https://www.theglobalfund.org/media/9811/trp_2020-

2022lessonslearnedwindow1_report_en.pdf

15. The Global Fund. TRP Lessons Learned from Review Window 2 of the 2020-2022 Funding

Cycle [Internet]. 2020. Available from: https://www.theglobalfund.org/media/10179/trp_2020-

2022lessonslearnedwindow2_report_en.pdf

16. HIV Policy Lab. Global HIV Policy Report [Internet]. Georgetown University; 2020.

Available from: https://www.hivpolicylab.org/reports/2020GlobalReport

17. Technical Review Panel Observations on the 2017-2019 Allocation Cycle [Internet].

Geneva, Switzerland: The Global Fund; 2019 Nov. Available from:

https://www.theglobalfund.org/media/9053/bm42_08-trppbservations2017-

2019allocationcycle_report_en.pdf?u=637319004066130000

18. The Global Fund. Technical Brief: Gender Equity [Internet]. 2019. Available from:

https://www.theglobalfund.org/media/5728/core_gender_infonote_en.pdf

19. The Global Fund. Technical Brief: Tuberculosis, Gender and Human Rights [Internet].

2020. Available from:

https://www.theglobalfund.org/media/6349/core_tbhumanrightsgenderequality_technicalbrie

f_en.pdf

20. The Global Fund. Technical Brief: HIV, Human Rights, and Gender Equality [Internet].

2019. Available from:

https://www.theglobalfund.org/media/6349/core_tbhumanrightsgenderequality_technicalbrie

f_en.pdf

21. Strategy Development, The Global Fund. Landscape Analysis - Human Rights, Gender

and Equity [Internet]. 2020 Jun 26. Available from:

https://www.theglobalfund.org/media/9839/strategydevelopment_2020humanrightsgendere

quity_landscapeanalysis_en.pdf

Annexes

Annex 1. Summary of countries eligible for matching funds in NFM2 and NFM3 by type.

Country

Funding

Cycle

TB:

Missing

cases

Human

Rights

HIV:

AGYW

HIV: KP

HIV:

self-

testing

RSSH:

Data

systems

Totals

Cambodia^

NFM2

$0.0

NFM3

$6.0

DRC

NFM2

$10.0

$3.0

$16.0

NFM3

$10.0

$2.6

$12.6

Mozambique

NFM2

$6.0

$4.7

$6.0

$3.0

$19.7

NFM3

$6.0

$4.0

$9.5

$2.9

$22.4

Myanmar^

NFM2

$10.0

$6.3

$3.0

$19.3

NFM3

$6.0

$6.3

$12.3

Senegal

NFM2

$1.5

$1.2

$0.0

NFM3

$1.2

Uganda

NFM2

$4.4

$5.0

$9.4

NFM3

$6.0

$4.4

$7.2

$2.9

$3.0*

$23.5

Totals

NFM2

$26.0

$13.6

$11.0

$7.5

$0.0

$9.0

$67.1

NFM3

$34.0

$12.2

$16.7

$6.3

$5.8

$3.0

$78.0

*Improved data science in community health

^In NFM3, excludes catalytic element of multi-country RAI in Cambodia ($15 million) and Myanmar ($40

million)

Annex 2. Qualitative data collected by PCE countries

CAM

DRC

GTM

MOZ

MYN

SEN

SUD

UGA

KIIs

Fact checking

meetings observed

documents reviewed

150

116

135

102

100

Annex 3. Approach to identification of human rights, gender, and other equity-related

investments

The PCE relied upon the Global Fund gender and human rights disease-specific technical briefs to

initially identify modules and interventions which contain investments related to human rights,

gender and other equity (HRG-Equity). (18–21) The list of these HRG-Equity-related modules and

interventions were shared with the Global Fund Secretariat and the Community, Rights and

Gender (CRG) team for review and feedback. After a consultative discussion and receiving a draft

methodology of how the CRG team has proposed tracking human rights-related investments, a

sub-categorization of these modules and interventions was included to allow for a clearer

understanding of the types of investments captured within the PCE’s HRG-Equity-related

investments. The sub-categories include 1) human rights-related investments, which align with

the CRG’s proposed methodology of “Opt-in modules and interventions,” 2) key and vulnerable

populations-related investments, and 3) other equity-related investments. Table 2.1 below shows

examples of modules and interventions included in each category; while the full list is extensive

(138 module/interventions pairs in total) and unable to be included in the text of the report, it

can be made available upon request.

Annex Table 2.1

Module

Intervention

Human

rights

funding

Key and

vulnerable

populations

funding

Other

equity

investments

Comprehensive prevention

programs for men who have

sex with men

Addressing stigma,

discrimination and violence

against men who have sex with

men

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Behavioral interventions for

men who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Condoms and lubricant

programming for men who

have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Diagnosis and treatment of

sexually transmitted infections

and other sexual health services

for men who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

HIV testing services for men

who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Interventions for young men

who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Behavioral interventions for

people who inject drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Community empowerment for

people who inject drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Condoms and lubricant

programming for people who

inject drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Diagnosis and treatment of

sexually transmitted infections

FALSE

TRUE

FALSE

III

and other sexual health services

for people who inject drugs

Comprehensive prevention

programs for people who

inject drugs and their partners

HIV testing services for people

who inject drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Interventions for young people

who inject drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Needle and syringe programs

for people who inject drugs and

their partners

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Behavioral interventions for sex

workers

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Condoms and lubricant

programming for sex workers

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

HIV testing services for sex

workers

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Interventions for young people

who sell sex

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Behavioral interventions for

transgender people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Condoms and lubricant

programming for transgender

people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

HIV testing services for

transgender people

FALSE

TRUE

FALSE

Prevention of mother-to-child

transmission

Prong 1: Primary prevention of

HIV infection among women of

childbearing age

FALSE

TRUE

Prevention of mother-to-child

transmission

Prong 3: Preventing vertical

HIV transmission

FALSE

TRUE

Prevention of mother-to-child

transmission

Prong 4: Treatment, care and

support to mothers living with

HIV, their children and families

FALSE

TRUE

Prevention programs for

adolescents and youth, in and

out of school

Other interventions for

adolescent and youth

FALSE

TRUE

Prevention programs for

general population

Gender-based violence

prevention and treatment

programs for general

population

FALSE

TRUE

Prevention programs for other

vulnerable populations

Behavioral interventions for

other vulnerable populations

FALSE

TRUE

FALSE

Prevention programs for other

vulnerable populations

HIV testing services for other

vulnerable populations

FALSE

TRUE

FALSE

Prevention programs for other

vulnerable populations

Male and female condoms for

other vulnerable populations

FALSE

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

HIV and HIV/TB-related legal

services

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

Improving laws, regulations and

polices relating to HIV and

HIV/TB

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

Sensitization of lawmakers and

law enforcement agents

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

Stigma and discrimination

reduction

TRUE

FALSE

TB/HIV

Key populations (TB/HIV) -

Others

FALSE

TRUE

FALSE

TB/HIV

Key populations (TB/HIV) -

Prisoners

FALSE

TRUE

FALSE

Treatment, care and support

Prevention, diagnosis and

treatment of opportunistic

infections

FALSE

TRUE

Multidrug-resistant TB

Community MDR-TB care

delivery

FALSE

TRUE

TB care and prevention

Community TB care delivery

FALSE

TRUE

TB care and prevention

Key populations (TB care and

prevention) – Others

FALSE

TRUE

FALSE

Differentiated HIV Testing

Services

Community-based testing

FALSE

TRUE

FALSE

Differentiated HIV Testing

Services

Facility-based testing

FALSE

TRUE

FALSE

Differentiated HIV Testing

Services

Self-testing

FALSE

TRUE

FALSE

PMTCT

Prong 2: Preventing unintended

pregnancies among women

living with HIV

FALSE

TRUE

PMTCT

Prong 3: Preventing vertical

HIV transmission

FALSE

TRUE

PMTCT

Prong 4: Treatment, care and

support to mothers living with

HIV, their children and families

FALSE

TRUE

Prevention

Addressing stigma,

discrimination, and violence

TRUE

FALSE

Prevention

Behavior change interventions

FALSE

TRUE

FALSE

Prevention

Community empowerment

FALSE

TRUE

FALSE

Prevention

Condom and lubricant

programming

FALSE

TRUE

FALSE

Prevention

Gender-based violence

prevention and post-violence

care

FALSE

TRUE

Prevention

Harm reduction interventions

for drug use

FALSE

TRUE

FALSE

Prevention

Interventions for young Key

Populations

FALSE

TRUE

FALSE

Prevention

Needle and syringe programs

FALSE

TRUE

FALSE

Prevention

Opiod substitution therapy and

other medically assisted drug

dependence treatment

FALSE

TRUE

FALSE

Prevention

Overdose prevention and

management

FALSE

TRUE

FALSE

Prevention

Pre-exposure prophylaxis

FALSE

TRUE

FALSE

Prevention

Prevention and management of

co-infections and co-

morbidities

FALSE

TRUE

FALSE

Prevention

Sexual and reproductive health

services, including STIs

FALSE

TRUE

FALSE

Reducing human rights-related

barriers to HIV/TB services

Human rights and medical

ethics related to HIV and

HIV/TB for health care

providers

TRUE

FALSE

Reducing human rights-related

barriers to HIV/TB services

Legal Literacy (""Know Your

Rights"")

TRUE

FALSE

Reducing human rights-related

barriers to HIV/TB services

Reducing HIV-related gender

discrimination, harmful gender

norms, and violence against

women and girls in all their

diversity

TRUE

FALSE

Reducing human rights-related

barriers to HIV/TB services

Stigma and discrimination

reduction

TRUE

FALSE

Treatment, care and support

Prevention and management of

co-infections and co-

morbidities

FALSE

TRUE

FALSE

Removing human rights and

gender related barriers to TB

services

Legal aid and services

TRUE

FALSE

TB care and prevention

Key populations - Children

FALSE

TRUE

FALSE

TB care and prevention

Key populations - Prisoners

FALSE

TRUE

FALSE

PMTCT

Prong 1: Primary prevention of

HIV infection among women of

childbearing age

FALSE

TRUE

Reducing human rights-related

barriers to HIV/TB services

Improving laws, regulations,

and policies relating to HIV and

HIV/TB

TRUE

FALSE

Community responses and

systems

Community-led advocacy

FALSE

TRUE

Case management

Integrated community case

management (iCCM)

FALSE

TRUE

FALSE

Specific prevention

interventions

Intermittent preventive

treatment – In pregnancy

FALSE

TRUE

FALSE

Specific prevention

interventions (SPI)

Intermittent preventive

treatment (IPT) - In infancy

FALSE

TRUE

FALSE

Specific prevention

interventions (SPI)

Intermittent preventive

treatment (IPT) - In pregnancy

FALSE

TRUE

FALSE

Integrated service delivery and

quality improvement

Quality of care

FALSE

TRUE

TB/HIV

Community TB/HIV care

delivery

FALSE

TRUE

TB/HIV

Key populations (TB/HIV) –

Prisoners

FALSE

TRUE

FALSE

Removing human rights and

gender related barriers to TB

services

Human rights, medical ethics

and legal literacy

TRUE

FALSE

Removing human rights and

gender related barriers to TB

services

Reform of laws and policies

TRUE

FALSE

Removing human rights and

gender related barriers to TB

services

Stigma and discrimination

reduction

TRUE

FALSE

TB care and prevention

Key populations - Miners and

mining communities

FALSE

TRUE

FALSE

TB care and prevention

Key populations - Mobile

populations: refugees, migrants,

and internally displaced people

FALSE

TRUE

FALSE

Community systems

strengthening

Community-led advocacy and

research

FALSE

TRUE

TB/HIV

Key populations - Children

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Community empowerment for

men who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Other interventions for men

who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Pre-exposure prophylaxis

(PrEP) for men who have sex

with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for men who have

sex with men

Prevention and management of

coinfections and co- morbidities

men who have sex with men

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Diagnosis and treatment of

sexually transmitted infections

and other sexual and

reproductive health services for

sex workers

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Other interventions for sex

workers and their clients

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Community empowerment for

transgender people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Diagnosis and treatment of

sexually transmitted infections

and sexual health services for

transgender people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Interventions for young

transgender people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Other interventions for

transgender people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Pre-exposure prophylaxis

(PrEP) and other biomedical

interventions for transgender

people

FALSE

TRUE

FALSE

Comprehensive prevention

programs for transgender

people

Prevention and management of

co-infections and co-

morbidities for transgender

people

FALSE

TRUE

FALSE

VII

Comprehensive prevention

programs for transgender

people

Prevention and management of

co-infections and co-

morbidities for transgender

people

FALSE

TRUE

FALSE

Comprehensive programs for

people in prisons and other

closed settings

Behavioral interventions for

people in prisons and other

closed settings

FALSE

TRUE

FALSE

Comprehensive programs for

people in prisons and other

closed settings

Community empowerment for

people in prisons and other

closed settings

FALSE

TRUE

FALSE

Comprehensive programs for

people in prisons and other

closed settings

Condoms and lubricant

programming for people in

prisons and other closed

settings

FALSE

TRUE

FALSE

Comprehensive programs for

people in prisons and other

closed settings

Diagnosis and treatment of

sexually transmitted infections

and other sexual and

reproductive health services for

people in prisons and other

closed settings

FALSE

TRUE

FALSE

Comprehensive programs for

people in prisons and other

closed settings

Other interventions for people

in prisons and other closed

settings

FALSE

TRUE

FALSE

HIV Testing Services

Differentiated HIV testing

services

FALSE

TRUE

FALSE

Prevention of mother-to-child

transmission

Other interventions for PMTCT

FALSE

TRUE

Prevention programs for

adolescents and youth, in and

out of school

Gender-based violence

prevention and treatment

programs for adolescents and

youth

FALSE

TRUE

Programs to reduce human

rights-related barriers to HIV

services

Legal literacy (“Know Your

Rights”)

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

Other intervention(s) to reduce

human rights- related barriers

to HIV services

TRUE

FALSE

Programs to reduce human

rights-related barriers to HIV

services

Training of health care

providers on human rights and

medical ethics related to HIV

and HIV/TB

TRUE

FALSE

Integrated service delivery and

quality improvement

Supportive policy and

programmatic environment

FALSE

TRUE

Reducing human rights-related

barriers to HIV/TB services

Community mobilization and

advocacy

TRUE

FALSE

Reducing human rights-related

barriers to HIV/TB services

Sensitization of law-makers and

law-enforcement agents

TRUE

FALSE

Community responses and

systems

Social mobilization, building

community linkages,

collaboration and coordination

FALSE

TRUE

TB care and prevention

Key populations (TB care and

prevention) – Prisoners

FALSE

TRUE

FALSE

TB care and prevention

Removing human rights- and

gender-related barriers to TB

care and prevention

TRUE

FALSE

VIII

Comprehensive prevention

programs for people who

inject drugs and their partners

Addressing stigma,

discrimination and violence

against people who inject drugs

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Opioid substitution therapy and

other drug- dependence

treatment for people who inject

drugs

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Addressing stigma,

discrimination and violence

against sex workers

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Community empowerment for

sex workers

FALSE

TRUE

FALSE

Comprehensive prevention

programs for sex workers and

their clients

Pre-exposure prophylaxis

(PrEP) for sex workers

FALSE

TRUE

FALSE

Prevention programs for other

vulnerable populations

Other interventions for other

vulnerable populations

FALSE

TRUE

FALSE

Prevention

Integration into national multi-

sectoral responses of AGYW

programs

FALSE

TRUE

Reducing human rights-related

barriers to HIV/TB services

HIV and HIV/TB related legal

services

TRUE

FALSE

Community systems

strengthening

Social mobilization, building

community linkages, and

coordination

FALSE

TRUE

Comprehensive prevention

programs for people who

inject drugs and their partners

Other interventions for people

who inject drugs and their

partners

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Overdose prevention and

management

FALSE

TRUE

FALSE

Comprehensive prevention

programs for people who

inject drugs and their partners

Prevention and management of

co-infections and co-

morbidities for people who

inject drugs

FALSE

TRUE

FALSE

Prevention programs for

adolescents and youth, in and

out of school

Behavioral change as part of

programs for adolescent and

youth

FALSE

TRUE

Prevention programs for

adolescents and youth, in and

out of school

HIV testing services for

adolescents and youth, in and

out of school

FALSE

TRUE

Prevention programs for other

vulnerable populations

Diagnosis and treatment of

sexually transmitted infections

and other sexual health services

for other vulnerable

populations

FALSE

TRUE

FALSE

MDR-TB

Key populations - Prisoners

FALSE

TRUE

FALSE

TB care and prevention

Key populations - Others

FALSE

TRUE

FALSE

TB/HIV

Key populations (TB/HIV) –

Others

FALSE

TRUE

FALSE

Prevention programs for

adolescents and youth, in and

out of school

Addressing stigma,

discrimination and legal

barriers to care for adolescents

and youth

TRUE

FALSE

Prevention programs for

adolescents and youth, in and

out of school

Community mobilization and

norms change

FALSE

TRUE

Prevention programs for

adolescents and youth, in and

out of school

Keeping girls in school

FALSE

TRUE

Prevention programs for

adolescents and youth, in and

out of school

Socioeconomic approaches

FALSE

TRUE

Programs to reduce human

rights-related barriers to HIV

services

Reducing HIV-related gender

discrimination, harmful gender

norms and violence against

women and girls in all their

diversity

TRUE

FALSE

Prevention programs for

adolescents and youth, in and

out of school

Linkages between HIV

programs and RMNCH

FALSE

TRUE

Specific prevention

interventions

Intermittent preventive

treatment – In infancy

FALSE

TRUE

FALSE

Specific prevention

interventions (SPI)

Removing human rights and

gender related barriers to

specific prevention

interventions

TRUE

FALSE

Annex 4. PCE 2020 Guidance on Operationalizing the 2S Framework

1. Purpose of this document

This document provides guidance for how to analyze whether “direct” RSSH investments in

current and upcoming Global Fund grants constitute health systems support or health systems

strengthening This guidance builds from references to 4S in both the RSSH and sustainability

guidance documents. Given the need for consistency in applying the framework to budgets in the

2017 and 2020 funding requests and across the four countries, GEP and CEP will work together

closely on the coding process. By examining the change over time, we will assess whether

countries have increased the proportion or Global Fund RSSH investments contributing to health

systems strengthening (versus support).

2. Health system investments: supporting vs. strengthening

The TRP report on RSSH investments in the 2017-2019 funding cycle applied the 4S framework

(start-up, support, strengthening, sustainability), which was an expansion of the framework

proposed by Grace Chee et al. (2013) describing systems support vs. systems strengthening

(hereafter “2S”) as visualized through the health systems cube (Figure 1). Through the TRP’s

review, it was noted that the ‘start-up’ and ‘sustainability’ categories of 4S (the outer two S) were

not applied very often, meaning that most Global Fund investments fell into either the ‘support’

or ‘strengthening’ categories (the middle two S) within the 4S continuum. For that reason, and in

consultation with the TRP, the PCE will apply the 2S framework, which will also help to increase

coding consistency by having fewer categories.

Figure 3.1. Systems Support and Systems Strengthening: Health Systems Cube (Chee et al. 2013).

The health system cube Y-axis includes the WHO building blocks, which are considered key

functions of the health system. The X-axis includes illustrative disease‐specific programs that

deliver critical services, while the third dimension along the Z axis includes performance drivers,

including inputs (systems support), policies, and regulations, organizational structures, and

behaviors (systems strengthening) (Chee et al. 2013). Our analysis will assess whether

proposed RSSH activities contribute to systems support versus system strengthening in

line with Figure 1 above. Per Chee et al. (2013):

• “Supporting the health system can include any activity that improves services, from

distributing mosquito nets to procuring medicines. These activities improve outcomes

primarily by increasing inputs.”

• “Strengthening the health system is accomplished by more comprehensive changes to

performance drivers such as policies and regulations, organizational structures, and

relationships across the health system to motivate changes in behavior and/or allow more

effective use of resources to improve multiple health services.”

The TRP methodology notes that funding requests examples that were health systems support

oriented included requests for cars, computers, phones, travel costs for routine monitoring,

furniture and office equipment, payments for fuels and maintenance of vehicles, cost for regular

training or overseas training, software, reimbursement for importation, among others. Whereas

funding requests characterized by more health systems strengthening interventions included

requests for upscaling of volunteer networks; developing protocols for data quality monitoring;

developing standard operating procedures for quality control in laboratories; transferring of the

procurement system of Global Fund into the national procurement systems; digitizing HMIS data;

developing strategies to engage with the private sector; providing technical assistance for DHIS2

roll-out, improving procurement and supply chain procedures including e-LMIS, and establishing

medicine regulatory authority, among others.

3. Data Sources for RSSH interventions/activities

PCE will rely on up to three budget types as source documents for applying 2S, pending data

availability:

1. Final approved budgets following grant making (2017)

○ To be independently coded by two GEP and compared to review any inconsistencies

and reach consensus on 2S codes.

○ The final approved grant making budget is preferable to the funding request budget,

as it represents the RSSH allocation actually planned for implementation.

2. Funding request budgets submitted to TRP (2020)

○ To be independently coded by GEP and CEP (and then compared in small working

group to review inconsistencies in coding and to reach consensus on 2S codes).

3. Final approved budgets following grant making (2020) for HIV in GTM

○ This may not be available for all countries by the end of 2020. Where available

following grant making, to be independently coded by GEP and CEP (and then

compared to review inconsistencies in coding and to reach consensus on 2S codes).

In addition to the budget data, the funding request narrative description of RSSH investments

should be used as a secondary source for triangulating with budget information when examining

interventions (or activities) and applying the 2S framework. The funding request narrative is

often not well aligned with the budget, unfortunately, but can still often be helpful in

understanding the overall scope of the RSSH interventions.

4. Steps for operationalizing 2S application to RSSH activities in Global Fund grants

4.1 Review the RSSH budget data

Relevant budget data will be extracted by GEP for each country to ensure we are using a

systematic data format across countries. In line with the detailed budgets, the template includes

columns (shaded green) for the extracted data: Grant, Grant Period, Module, Intervention, Activity

Description, Cost Input, and Budget. Additional columns (shaded blue or purple) for data entry

XII

by coders include Scope, Longevity, Approach, Designation (Supporting vs. Strengthening) and

Justification.

Review budget data for each line item, examining the module, intervention, and activity

description. In addition, review the Cost Input categorization. Together, these four data elements

should yield sufficient information to understand the RSSH activity. In some cases, where this

data is insufficient, the funding request narrative can be referred to for additional description of

the RSSH interventions.

HMIS/M&E Investments

RSSH investments in many PCE countries contain substantial investments in HMIS/M&E modules.

While as for other modules, determining whether HMIS/M&E investments are strengthening or

supporting requires careful review of the activity description, our review of the 2017 budgets has

revealed a few patterns. Generally speaking, activities (meetings, etc) related to data validation

(especially when part of the analysis/review intervention category) can be considered

strengthening. Activities related to monitoring the performance of the Global Fund grants

themselves (as opposed to strengthening country M&E systems) should be considered supporting.

Some activities aimed at improving internet connectivity to support information systems

strengthening can also be considered strengthening because, although an input, efforts to improve

the collection and use of data is persistently hampered by poor connectivity, and therefore this

may be a foundational investment upon which broader strengthening efforts are dependent. Other

activities (training, supervision, etc) related to the roll-out of DHIS2 (or similar system) can be

considered strengthening.

4.2 Consider the Scope, Longevity, and Approach of each RSSH intervention/activity pair, and the

cost input category

Drawing from the TRP’s methodology, we will apply three criteria--scope, longevity, and

approach--to assess each RSSH intervention/activity pair in the budget. These three criteria,

along with the Cost Input categorization, will be taken together in determining the designation of

“supporting” or “strengthening”. With the exception of Justification (which requires the coder to

type a justification for why they selected supporting or strengthening, these columns all contain

dropdown menus for the definitions of Scope, Longevity, Approach, and Designation to ease the

coding process. The criteria for a system strengthening intervention include:

• Scope: activities have impact across health services and outcomes

• Longevity: effects will continue after activities end

• Approach: revise policies and institutional relationships to change behaviors and

resource use to address identified constraints in a more sustainable manner

The definitions of Scope, Longevity, and Approach included in the table below will be used for

determining whether an activity is systems support versus systems strengthening.

Parameter

System Support

System Strengthening

Scope

May be focused on a

single disease or

intervention

Activities have impact across health services and

outcomes; and systems may be integrated into the

overall health sector

Longevity

Effects limited to

period of funding

Effects will continue after funded activities end

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Approach

Provide inputs to

address identified

system gaps

Revise policies and institutional relationships to change

behaviors and resource use to address identified

constraints in a more sustainable manner

In many cases, if the majority of the three (scope, longevity and approach) criteria are designated

support or strengthening (i.e. at least 2 out of 3), that will be sufficient to determine the final

designation for the row. There are some cases, where one or more of the criteria may be

designated as unclear, even after considering the cost input category (see below), resulting in a

1-1 tie. These instances will require more of a qualitative judgment to arrive at a final

determination and should be discussed between coders to ensure agreement.

Cost input categories

There are minimum budget requirements for Global Fund funding request submissions, including

modules and their related interventions (selected from prescribed list in the Modular Framework

Handbook) and cost groupings and cost inputs selected from a prescribed list (see Appendix 1, p.

77 of Global Fund guidelines for budgeting). In addition to considering the scope, longevity and

approach criterion in determining whether an activity is supporting or strengthening, certain cost

categories (as indicated in the Table below) can inform this categorization.

Cost Grouping

Cost Input Categories

Supporting / Strengthening

1. Human

resources

1.1 Salaries - program management

1.2 Salaries -outreach workers, medical

staff and other service providers

1.3 Performance-based supplements,

incentives

1.4 Other human resources costs

1.5 Severance costs (added to 2019

guidelines)

1.1/1.2 Considered supporting as

a health system input--including

payment for salaries and other

financial incentives

1.3 Performance-based

supplements and incentives are

the exception to this rule and can

be considered strengthening.

2. Travel-related

costs

2.1 Training-related per

diems/transport/other costs

2.2 TA-related per

diems/transport/other costs

2.3 Supervision/surveys/data

collection-related per

diems/transport/other costs

2.4 Meeting/advocacy-related per

diems/transport/other costs

2.5 Other transportation costs

Most often considered supporting

as a health system input.

2.1 Training-related per-

diems/transport/other costs

should be considered supporting,

unless activity description clearly

describes strengthening capacity

in relation to data use, data

validation meetings, financial

management, PSM, M&E, or other

systems strengthening related

area)

2.4 Meeting related costs

generally considered supporting

unless the activity description

indicates that the purpose is for

policy change or development.

XIV

3. External

professional

services

3.1 Technical assistance

fees/consultancy fees

3.2 Fiscal/fiduciary agent fees

3.3 External audit fees

3.4 Other external professional services

3.5 Insurance related costs

3.1 Technical assistance may be

considered strengthening but

this determination depends upon

review of the activity description.

4. Health products

-- pharmaceutical

products

4.1 Antiretroviral medicines

4.2 Anti-tuberculosis medicines

4.3 Antimalarial medicines

4.4 Opioid substitutes medicines

4.5 Opportunistic infections and STI

medicines

4.6 Private sector subsidies for ACTs

(co-payment to 4.3)

4.7 Other medicines

Most often considered supporting

as a health system input (e.g.

medicines for HIV, TB, malaria);

unlikely to be tagged within RSSH

modules

5. Health products

-- non-

pharmaceuticals

5.1 Insecticide-treated nets (long-

lasting insecticidal nets/insecticide-

treated nets)

5.2 Condoms –male

5.3 Condoms –female

5.4 Rapid diagnostic tests

5.5 Insecticides

5.6 Laboratory reagents

5.7 Syringes and needles

5.8 Other consumables

5.9 Private sector subsidies for rapid

diagnostic tests (Co-payments to 5.4)

Most often considered supporting

as a health system input (e.g.

bednets, condoms, RDTs,

insecticides, reagents, syringes);

unlikely to be tagged within RSSH

modules

6. Health products

-- equipment

6.1 CD4 analyzer/accessories

6.2 HIV viral load analyzer/accessories

6.3 Microscopes

6.4 TB molecular test equipment

6.5 Maintenance and service costs for

health equipment

6.6 Other health equipment

Unlikely to be tagged within RSSH

modules

7. Procurement

and supply chain

management costs

7.1 Procurement agent and handling

fees

7.2 Freight and insurance costs (health

products)

7.3 Warehouse and storage costs

7.4 In-country distribution costs

7.5 Quality assurance and quality

control costs

7.6 Procurement and supply

management customs duties and

clearance charges

7.7 Other procurement and supply

management costs

Cost inputs in this group are most

often considered supporting

7.5 (quality assurance and quality

control costs) and 7.7 (other

procurement and supply

management costs) are possible

exceptions which might be

considered strengthening,

depending on the activity

description

8. Infrastructure

8.1 Furniture

8.2 Renovation/constructions

8.3 Infrastructure maintenance and

other infrastructure costs

9. Non-health

equipment

9.1 IT -computers, computer

equipment, software and applications

9.2 Vehicles

9.3 Other non-health equipment

9.4 Maintenance and service costs non-

health equipment

9.1 IT equipment can typically be

categorized as strengthening if it

is intended to build data systems

capacity. Equipment to facilitate

stand-alone disease-specific

activities may be considered

support, but we haven’t seen

examples of this yet.

9.2 Vehicles are always support.

9.3 Varies, so closely review

activity descriptions. Lab-

strengthening equipment

purchases are generally

considered to be strengthening,

and tend to fall within this cost

input category

10.

Communication

material and

publications

10.1 Printed materials (forms, books,

guidelines, brochure, leaflets, etc.)

10.2 Television/radio spots and

programs

10.3 Promotional material (t-shirts,

mugs, pins, etc.) and other

communication material and

publications costs

All inputs within this cost

grouping are generally considered

to be supporting

11. Indirect and

overhead costs

11.1 Office-related costs

11.2 Unrecoverable taxes and duties

11.3 Indirect cost recovery -% based

11.4 Other PA costs

11.5 Shared costs

All inputs within this cost

grouping are generally considered

to be supporting

12. Living support

to client/target

population

12.1 Support to orphans and other

vulnerable children (school fees,

uniforms, books, etc.)

12.2 Food and care packages

12.3 Cash incentives/transfer to

patients/beneficiaries/counselors/

mediators

12.4 Microloans and microgrants

12.5 Other costs related to living

support to client/target population

Unlikely to be tagged within RSSH

modules

13. Payment for

results

Added to 2019 guidelines:

13.1 Results Based Financing

13.2 Activity Based Contracts,

Community Based Organizations and

other service providers

13.1 and 13.4 are generally

considered to be considered

strengthening

XVI

13.3 Incentives for Principal Recipient

and Sub-Recipients staff members

13.4 Incentives for Community Health

Workers (CHW), outreach workers,

medical staff and other service

providers

4.3 Review the funding request narrative to inform categorization

In some cases, the intervention/activity description and cost-inputs are very vague and provide

insufficient information on which categorize activities as supporting or strengthening. In these

instances, before making a final determination refer back to the funding request narrative to see

if there is additional context around interventions to help inform the final categorization. If no

such information exists, then apply the ‘unclear’ category. Note: In our review of the 2017 budgets,

we found very few interventions which required us to return to the funding request narratives, and

that could not be categorized after exhausting all of these options.

4.4 Review the other coder’s categorization and identify any discrepancies

Each budget will be coded twice, by one CEP and one GEP member. After completing coding of

the budgets, assign one person to compare and identify any lines where the final designation of

supporting vs. strengthening is not consistent between coders. Schedule a call to discuss each of

those discrepancies and align on the final designation. If needed, consult with other members of

the 2S working group to see if parallels can be drawn with other countries.

4.5 Quantify the proportion of the RSSH funds allocated to supporting vs. strengthening investments.

When final designations have been determined, quantify the proportion of funds going to

supporting vs strengthening investments. This can then be compared to 2017 investments to see

whether there is evidence of increased allocation of funds toward strengthening (which could be

considered evidence of a ‘changing trajectory’, or whether the allocations are similar to 2017

(which could be considered evidence of ‘business as usual’). Depending on what we find, we may

drill down to look in greater detail at change for specific modules or intervention categories

(which may be related to focus topics, e.g. HMIS/M&E) and may consider using Tableau to help

illustrate some of these findings. We will continue to build out our approach to this as we explore

the data and patterns or findings begin to emerge.

XVII

Annex 5. Supplemental figures of budget changes by disease and RSSH

In all figures, revision is the most recent official budget revision.

Annex Figure 5.1. Budget variance in HIV investments between NFM2 and NFM3.

Annex Figure 5.2. Budget variance in malaria investments between NFM2 and NFM3.

*Program Continuation in NFM2 did not require budget as part of the Funding Request; this data is not available for DRC, Mozambique,

Senegal and Sudan

**The first revision in DRC added an additional US$141,533,250 for the bed net mass distribution campaign that was originally going

to be implemented by PSI and was instead implemented by Global Fund PRs

***Funds for malaria, TB, and RSSH in Senegal remained unchanged between NFM3 FR and Approved Budgets. However, program

management funds for malaria are collapsed with those for TB in these figures due to the integration of some of the malaria component

within the TB/RSSH grant.

XVIII

Annex Figure 5.3. Budget variance in TB investments between NFM2 and NFM3.

Annex Figure 5.4. Budget variance in RSSH investments between NFM2 and NFM3

Figure note: Percentages represent the share of total budget RSSH modules made up for each respective

budget version. NFM2 Funding Requests (FR) could not be included for grants which were continuations

from NFM1—specifically for DRC, Senegal, and Sudan.

Given updates to the Modular Framework in 2019, for comparing similar RSSH modules across NFM2 and NFM3, we aligned across

funding cycles, e.g., “community responses and systems” (NFM2) comparable to “community systems strengthening” (NFM3);

“national health strategies” (NFM2) comparable to “health sector governance and planning” (NFM3); “procurement and supply chain”

(NFM2) comparable to “health products management systems” (NFM3). In addition, “laboratory systems” (red) was added as a

distinct module in NFM3, but in NFM2 was included as an intervention within the “Integrated Service Delivery” (pink) module.

The data presented does not include all disease components in some countries. Cambodia and Myanmar do not include data for

malaria. Sudan does not include data for HIV and TB. Only HIV is included for Guatemala in NFM3.

XIX

Annex 6. Table of cumulative absorption by year for all modules, RSSH modules, and

HRG-Equity-related modules

Country

Modules

Year

Cumulative

Expenditure

Cumulative Budget

Absorption

All Countries

All modules

2018

$ 435,221,116

$ 637,529,912

68%

All Countries

All modules

2019

$ 1,010,827,839

$ 1,243,020,973

81%

All Countries

All modules

2020

$ 774,919,591

$ 1,033,503,661

75%

All Countries

RSSH

2018

$ 24,252,479

$ 59,818,215

41%

All Countries

RSSH

2019

$ 40,085,859

$ 79,182,340

51%

All Countries

RSSH

2020

$ 38,861,769

$ 71,864,527

54%

All Countries

HRG-Equity

2018

$ 26,490,910

$ 54,175,617

49%

All Countries

HRG-Equity

2019

$ 81,579,875

$ 116,076,973

70%

All Countries

HRG-Equity

2020

$ 40,967,119

$ 80,258,075

51%

Cambodia

All modules

2018

$ 11,788,588

$ 22,030,647

54%

Cambodia

All modules

2019

$ 33,449,455

$ 45,208,043

74%

Cambodia

RSSH

2018

$ 269,245

$ 707,626

38%

Cambodia

RSSH

2019

$ 1,161,296

$ 2,127,055

55%

Cambodia

HRG-Equity

2018

$ 1,504,385

$ 2,855,512

53%

Cambodia

HRG-Equity

2019

$ 4,119,724

$ 5,901,577

70%

DRC

All modules

2018

$ 123,142,804

$ 187,137,531

66%

DRC

All modules

2019

$ 271,907,215

$ 341,325,377

80%

DRC

All modules

2020

$ 412,216,321

$ 565,885,160

73%

DRC

RSSH

2018

$ 11,745,365

$ 23,005,174

51%

DRC

RSSH

2019

$ 15,191,099

$ 24,878,992

61%

DRC

RSSH

2020

$ 31,165,051

$ 54,150,564

58%

DRC

HRG-Equity

2018

$ 4,771,951

$ 12,737,267

37%

DRC

HRG-Equity

2019

$ 14,521,128

$ 23,683,135

61%

DRC

HRG-Equity

2020

$ 16,915,414

$ 28,104,393

60%

Guatemala

All modules

2019

$ 12,568,696

$ 21,025,472

60%

Guatemala

All modules

2020

$ 6,653,971

$ 13,364,136

50%

Guatemala

RSSH

2019

$ 806,011

$ 1,998,652

40%

Guatemala

RSSH

2020

$ 441,170

$ 2,084,918

21%

Guatemala

HRG-Equity

2019

$ 2,218,054

$ 3,526,162

63%

Guatemala

HRG-Equity

2020

$ 3,108,291

$ 6,804,475

46%

Mozambique

All modules

2018

$ 90,247,014

$ 134,362,850

67%

Mozambique

All modules

2019

$ 319,921,010

$ 357,429,377

90%

Mozambique

RSSH

2018

$ 1,811,418

$ 13,645,166

13%

Mozambique

RSSH

2019

$ 11,349,364

$ 26,997,164

42%

Mozambique

HRG-Equity

2018

$ 3,841,326

$ 6,331,732

61%

HRG-Equity investments in Sudan were only analyzed for malaria, and were very small. Nonetheless, absorption

against these areas was 0%. 2020 expenditure, budget, and absorption figures only reflect the first semester.

Mozambique

HRG-Equity

2019

$ 18,964,823

$ 21,238,368

89%

Myanmar

All modules

2018

$ 54,094,227

$ 73,507,181

74%

Myanmar

All modules

2019

$ 52,175,815

$ 78,649,237

66%

Myanmar

RSSH

2018

$ 7,362,593

$ 9,458,290

78%

Myanmar

RSSH

2019

$ 3,686,430

$ 7,620,775

48%

Myanmar

HRG-Equity

2018

$ 11,386,127

$ 14,968,265

76%

Myanmar

HRG-Equity

2019

$ 23,740,879

$ 28,033,573

85%

Senegal

All modules

2018

$ 18,994,323

$ 30,327,752

63%

Senegal

All modules

2019

$ 43,548,244

$ 51,378,861

85%

Senegal

All modules

2020

$ 77,008,620

$ 85,834,261

90%

Senegal

RSSH

2018

$ 2,026,230

$ 4,538,079

45%

Senegal

RSSH

2019

$ 5,037,052

$ 7,392,846

68%

Senegal

RSSH

2020

$ 5,705,050

$ 9,457,464

60%

Senegal

HRG-Equity

2018

$ 3,010,466

$ 3,892,393

77%

Senegal

HRG-Equity

2019

$ 6,747,325

$ 8,167,893

83%

Senegal

HRG-Equity

2020

$ 6,472,849

$ 9,754,681

66%

Sudan

All modules

2018

$ 28,408,002

$ 39,989,280

71%

Sudan

All modules

2019

$ 43,720,610

$ 53,498,940

82%

Sudan

RSSH

2018

$ 775,227

$ 4,552,725

17%

Sudan

RSSH

2019

$ 1,390,904

$ 3,017,984

46%

Sudan

HRG-Equity

2018

$ -

Sudan

HRG-Equity

2019

$ -

$ 91,282

Uganda

All modules

2018

$ 108,546,157

$ 150,174,671

72%

Uganda

All modules

2019

$ 233,536,793

$ 294,505,666

79%

Uganda

All modules

2020

$ 279,040,679

$ 368,420,104

76%

Uganda

RSSH

2018

$ 262,400

$ 3,911,156

Uganda

RSSH

2019

$ 1,463,702

$ 5,148,873

28%

Uganda

RSSH

2020

$ 1,550,498

$ 6,171,580

25%

Uganda

HRG-Equity

2018

$ 44,551,947

$ 75,761,952

59%

Uganda

HRG-Equity

2019

$ 23,610,161

$ 28,606,493

83%

Uganda

HRG-Equity

2020

$ 33,098,451

$ 49,673,788

67%

XXI

Annex 7: Application of the Global Fund’s performance-based funding model

Introduction

The annual funding decision and disbursement processes are key to the Global Fund

Secretariat’s grant management function and performance-based funding model. The objective

of these processes is to: (6)

• review grant implementation progress (including achievement of programmatic targets,

and financial and management issues) and assign an overall grant rating;

• determine the funding to be disbursed for each grant for the following 12-month period;

and

• identify implementation issues, risks and mitigating measures.

The annual funding decision is intended to encourage grant recipients to focus on results and

timely implementation by being based on the principle of performance-based funding—i.e.,

where funding is reduced for poor performance and increased for high performance. (6)

Grant ratings in PCE countries

The grant rating is based on:

• Indicator rating: Quantitative assessment of progress against the targets in the

Performance Framework which is adjusted based on the Country Team’s understanding

of the quality of data and programmatic performance of the grant.

• Grant management issues: Qualitative assessment of whether issues exist across the

areas of M&E, program management, financial management and systems, and health

product management.

As shown in Table 1.1, across all grants in the eight PCE countries over the period 2018 to mid-

2020, the majority of grant ratings are applied to the B1 and A2 categories reflecting moderate

performance.

Annex Table 6.1: Frequency of grant ratings for all grants in PCE countries (2018-20)

Rating

Description

Frequency

Exceeds expectations

Meets expectation

16%

Adequate

65%

Inadequate but potential demonstrated

Unacceptable

Of interest, and as partly shown in Annex Figure 6.1, grant ratings change dramatically between

semesters in some instances (such as the TASO TB/HIV grant in Uganda which moved from a C

rating in Jan-Jun 2018 to a B2 rating in Jun-Dec 2018 to a B1 rating in Jan-Jun 2019 to an A1 rating

in Jun-Dec 2019), although there are no clear trends to discern across all countries.

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Annex Figure 6.1: Frequency of grant ratings by semester for all grants in PCE countries

Disbursements

According to the Operational Policy Note on Annual Funding Decisions and Disbursements, the

annual funding amount should be based on: (a) an indicative annual funding range based on the

indicator rating; (b) the rate of expenditure/absorption; and (c) the presence of grant

management issues. Table 1.2 sets out how the indicator rating is used to derive an annual

funding range, with a clear link between indicator performance and the proportion of the budget

to be disbursed in the following reporting period.

Annex Table 6.2: Use of indicator ratings to determine the indicative funding range

Indicator

rating

Target

achievement

Indicative funding range

>100%

Between 90-100% of Cumulative Budget through the next

reporting period

90-100%

60-89%

Between 60-89% of Cumulative Budget through the next

reporting period

30-59%

Between 30-59% of Cumulative Budget through the next

reporting period

<30%

To be discussed individually

As shown in Table 1.3, in the vast majority of instances where a grant attained an indicator rating

of b1 or b2 at the end of 2018, the level of funding disbursed in 2018 and 2019 exceeded the

indicative funding range, often dramatically. As such, the indicative funding range does not

appear to have influenced the annual funding decision and level of disbursements made. Rather,

evidence suggests that disbursement decisions are made by Country Teams primarily based on

financial needs, and possibly also qualitative information on performance.

Analysis suggests that this may be appropriate given that indicator performance is often not a

good proxy for what grants have implemented and achieved. It can also be reasonable not to

reduce funding to poorly performing grants after only a year of implementation. As such, the

utility of the indicator rating and how this is used to incentivize performance is unclear.

There are two important caveats to this analysis:

• The budgets used for this analysis are as at the grant award, and could have changed by

the time (i.e., after the end of 2018) the annual funding decision was made.

• The indicative funding ranges are designed to serve as a “starting point” for the Country

XXIII

Team in determining the annual funding amount, and there may be valid reasons for

disbursing outside these ranges. We would nonetheless expect the analysis to show

some pattern between the indicator rating and the level of disbursements made.

Annex Table 6.3: Actual % of budget disbursed in 2018-19 compared to indicative funding

range for 2018-19, based on the indicator rating at end-2018

Grant

Indicator rating

(end-2018)

Indicative funding range for

2018-19 budget

Actual % of budget

disbursed (2018-19)

KHM-C-MEF

60-89%

105%

MOZ-C-CCS

30-59%

92%

MOZ-H-FDC

60-89%

128%

MOZ-H-MOH

90-100%

61%

MOZ-M-MOH

90-100%

62%

MOZ-M-WV

90-100%

93%

MOZ-T-MOH

60-89%

76%

MMR-H-UNOPS

60-89%

83%

MMR-T-SCF

90-100%

92%

MMR-H-SCF

90-100%

93%

MMR-T-UNOPS

60-89%

84%

SDN-H-UNDP

60-89%

113%

SDN-T-UNDP

60-89%

120%

SDN-M-MOH

60-89%

107%

UGA-H-MoFPED

60-89%

98%

UGA-T-MoFPED

90-100%

110%

UGA-C-TASO

30-59%

144%

UGA-M-MoFPED

60-89%

165%

UGA-M-TASO

60-89%

163%

SEN-Z-MOH

30-59%

117%

SEN-H-ANCS

90-100%

106%

SEN-H-CNLS

60-89%

104%

SEN-M-PNLP

60-89%

80%

GTM-T-MSPAS

60-89%

310%

GTM-M-MSPAS

60-89%

147%

COD-H-MOH

60-89%

93%

COD-C-CORDAID

60-89%

119%

COD-M-SANRU

90-100%

93%

COD-M-MOH

90-100%

99%

COD-T-MOH

60-89%

99%