Global Fund Approach to Health System Strengthening WHO Expert consultation on positive synergies between health systems and Global Health Initiatives Geneva, 29-30 May 2008 Dr Stefano Lazzari, Director a.i., Health Advisory Unit
The Global Fund to Fight AIDS, TB and malaria The Global Fund is an independent public-private partnership established in 2001. We are mandated to: - Raise and to disburse substantial new funds - Operate transparently and accountably Spend i - Achieve sustained impact on HIV/AIDS, TB, and malaria BG/290607/1
Why invest in Health Systems? Maximise Global Fund investments and promote sustainability Reduce the risks and unintended consequences Achieve Global Fund objectives by removing obstacles to improved HIV, TB and malaria outcomes GF Framework Document (2001) states that it will support programs that address the three diseases in ways that strengthen health systems. In April 2007, the Fifteenth Board meeting reaffirmed that the Fund's strategic approach to health system strengthening consists of 'investing in activities to help health systems overcome constraints to the achievement of improved outcomes in reducing the burden of HIV/AIDS, TB and malaria.
Biggest obstacles to improved HIV, TB, malaria outputs / outcomes Availability, skills, motivation of health workers Drug procurement and distribution systems Diagnostic services Access to health services especially financial access Management and co-ordination of services Health information and monitoring systems
Contribution of Global Fund Grants to Health Systems Strengthening Direct funding of health systems components Positive externalities of support provided to disease targeted programs for the whole health systems Reducing the burden of major diseases => workload for health systems microeconomic productivity macroeconomic growth
Reducing the workload for health systems Declining laboratory-confirmed malaria cases in health facilities after interventions, Rwanda, 2001-2007 4,500 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500 0 Jan-01 Feb-01 Mar-01 Apr-01 May-01 Jun-01 Jul-01 Aug-01 Sep-01 Oct-01 Nov-01 Dec-01 Jan-02 Feb-02 Mar-02 Apr-02 May-02 Jun-02 Jul-02 Aug-02 Sep-02 Oct-02 Nov-02 Dec-02 Jan-03 Feb-03 Mar-03 Apr-03 May-03 Jun-03 Jul-03 Aug-03 Sep-03 Oct-03 Nov-03 Dec-03 Jan-04 Feb-04 Mar-04 Apr-04 May-04 Jun-04 Jul-04 Aug-04 Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Malaria in-patient and out-patient laboratory-confirmed cases Month 7,000 6,000 5,000 Non-malaria in-patient cases Interventions Malaria in-patient cases Out-patient confirmed cases Non-malaria in-patient cases Incidence ~75% 4,000 3,000 2,000 1,000 0
Direct Funding of Health Systems through GF Grants through disease grants and cross-cutting HSS (2007) Commodities, Products, Drugs 45% Other 10% Administration 10% Health Systems 35% Monitoring and Evaluation 3% Infrastructure and Equipment 9% Human Resources 23% Estimates from Global Fund Rounds 2-7 proposals 100% = $5.2 billion USD
HSS Round 7 analysis by TRP 75% (113 / 150) eligible proposals contained HSS 'strategic actions' Most applicants had 3 or more strategic actions Amount recommended for HSS strategic actions was $363 million (13% of total) Of the requested support 68% was included within HIV/AIDS components 22% within malaria components 10% within TB components Recommendation to maintain Round 7 HSS question framework The TRP continues to believe that there is much greater opportunity for health system strengthening than is currently being accessed.
WHO consultation on GF approach to HSS September 2007 Main recommendations: Maximum flexibility recognizing differences in country needs and situations Keep parameters for allowable HSS activities as broad as possible Avoid ceilings Support HSS interventions that, by removing system bottlenecks, improve HIV, TB and malaria outcomes Essential role of information, TA and coordination and cooperation at country level Opinions remained divided on whether countries should apply or not through a separate HSS component or window
GF Health Systems Strengthening Approach Global Fund Board decision (GF/B16/DP10 extract only) "The Global Fund shall encourage applicants, wherever possible, to integrate requests for funding for HSS actions within the relevant disease component(s)." "Recognizing that some HSS actions ( cross-cutting HSS actions ) may significantly benefit more than one disease, the Global Fund shall allow applicants to request funding for such HSS actions by completing a distinct but complementary section (a cross-cutting HSS section ) within a disease component" 10
Summary of GF HSS approach Support HSS interventions that, by removing system bottlenecks, contribute to HIV, TB and malaria outcomes Broad flexibility regarding HSS actions eligible for funding; No budget ceiling No priority list of interventions, but the Global Fund will not finance large infrastructure projects or vaccine research, efficacy trials, or vaccine development Where possible, integrate HSS requests within a disease component Where HSS actions benefit more than one disease, applicants can complete a distinct, complementary section within a disease component (a cross cutting section). One country application may only contain one HSS cross-cutting section TRP flexibility when reviewing proposals Proposal process: essential involvement of relevant HSS stakeholders in CCM and in proposal development process
TRP Flexibility When Reviewing Proposals Historically TRP required to review 'disease proposal' as a whole Recognized this may have acted as a disincentive to cross-cutting HSS proposals Round 8 Proposal form has a disease part (4.5.1) and a HSS cross-cutting part (4B) TRP is mandated to review and recommend: The whole 'disease proposal' including the cross-disease part (s.4b); or The disease interventions (s.4.5.1) but not the cross-disease part (s.4b); or The cross-disease part (s.4b) but not the disease interventions (s.4.5.1). Intent: To remove unintended barriers to cross-disease responses due to fears of undermining the approval of the disease component