Exploring Global Fund processes in three African countries
Across the East and Southern Africa regions, the Global Fund to Fight AIDS, TB and Malaria is a lead financier of national responses to HIV. Within its current portfolio of HIV grants, three of the Global Fund’s largest investments are in Malawi, Tanzania and Zimbabwe, countries which each receive as much as US$500 million in three-year programme grants. The way that countries plan for, receive, and implement these grants has major impacts on their ability to manage their HIV epidemics.
The Bill & Melinda Gates Foundation is also an important partner in Malawi, Tanzania and Zimbabwe where it is working with governments and other stakeholders to improve the effectiveness and impact of national HIV programmes. Given the central role of the Global Fund in these countries, it is imperative for the foundation and other technical partners like it, to understand how grants are planned for, structured and implemented so that their work can be fully aligned with these contributions.
- Identify challenges, gaps and opportunities in both the funding request development process and grant implementation stages.
- Establish a clear roadmap of solutions for strengthening Global Fund investments in Malawi, Tanzania and Zimbabwe.
- In addition to identifying actionable solutions, identify the stakeholders best equipped to implement the recommended solutions where possible.
Data collection involved document reviews, key informant interviews, focus group discussions and participant observation at meetings and other events, covering the period from February to October 2017, which coincided with preparations for a new Global Fund grant cycle in
each country. Data analysis involved standard qualitative (thematic analysis) and quantitative (calculation means and proportions) methods, as well as triangulation. There were some limitations to the methodology, which included challenges to access some documentation and data, as noted in the report where relevant, and the reliance on stakeholder perceptions without, in some cases, the ability to independently confirm the validity or accuracy of what they described.
- All countries are strongly committed to inclusive processes for planning, monitoring and oversight of Global Fund programmes. However, since most funds are now applied to support multi-year HIV treatment needs, the relevance and effectiveness of these commitments comes into question given the limited scope for flexibility in decision-making on the use of what few Global Fund resources remain.
- Global Fund implementation structures continue to be largely vertical with their own complex financial and administrative management requirements, and operating for the most part outside of established health and community systems. This can increase transaction costs and inhibit integration and sustainability.
- Despite several years of investment in systems strengthening, health human resources, financial management, procurement and supply management, and monitoring and evaluation arrangements continue to cause challenges and to negatively affect grant performance and fund absorption.
- Reprogramming is not always undertaken proactively to shift resources to non-treatment priorities such as prevention. It sometimes occurs very late in the grant implementation period, increasing the risk that some funds remain unused.
- Although the Global Fund continues to work with countries to increase their domestic financing of national HIV responses, only small, incremental changes are occurring with significant risks emerging for HIV treatment programmes should there be even small changes in funding levels in future grant cycles.
A contextual analysis of country needs and priorities regarding HIV, TB and other health concerns.
A descriptive analysis of Global Fund investments and the processes that guide these investments, such as country dialogue, finding request development, grant-making and grant implementation arrangements.
Recommendations on how to improve Global Fund processes.