The Global Fund to fight AIDS, TB and malaria is one of the most important financers of AIDS, TB and malaria in the world, in many countries it is the major source of finances for prevention, treatment and care of these three diseases. So asking what difference it is making is highly relevant to larger discussions around global health and development.
In 2015 Itad, together with Euro Health Group and the University of California, San Francisco, was commissioned by the Global Fund’s independent Technical Evaluation Review Group to conduct a Strategic Review (SR2015) of the Global Fund’s contribution to reducing the three diseases and the progress being made in implementing its 2012 – 2016 strategy. The scope of the SR2015 was challenging on many fronts, not least that one arm of the review was backwards looking, i.e. focused on what difference Global Fund finances had made in the previous decade, while the other arm was more forward looking, using current experience to inform thinking around the Global Fund’s future strategy beyond 2016.
Given the scope of the review we took a ‘theory based approach’, both in considering the contribution of the Global Fund in the previous decade and in looking at strategy implementation progress. Exploring the contribution of the Global Fund’s inputs, our UC San Francisco team members used ‘plausibility analysis’ to explain the downward disease trends they were finding in the case study countries they focused on. Overall they concluded that it was plausible to suggest that increased funding for the three diseases had led to a reduction in national HIV, TB and malaria burden, and that therefore levels of funding are an important factor in bringing about disease impact.
For the review of the 2012 -2016 strategy the Itad/EHG team developed a retrospective ‘theory of change’ (in the absence of there being an explicit one already developed) on the basis of what was written in the strategy itself, what was available in other contemporary, internal strategic documents, and what Global Fund staff who had been involved in strategy development were able to tell us. Frameworks for ‘theories of change’ vary tremendously. Our tactic was to consider four main categories of factors that could effect change:
- Remote factors (those conditions that the Global Fund has no control over, such as national political economies or the global economy)
- Proximate factors (those conditions the Global Fund has direct control over, such as grant management processes)
- Intermediate factors (those conditions that happen between what the Global Fund has control over and intended outcomes, such as country willingness to increase health sector financing)
- Country outcomes (the health system related conditions that lead to health impact)
Using extensive document review and stakeholder interviews, including reviews of the experience of sixteen countries chosen for their diversity of epidemics, economies and location we found that Global Fund strategy implementation was still in its early stages. The strategy itself laid out some fundamental shifts in the way the Global Fund could approach how it works with countries and grant recipients. At the stage when the SR2015 was being conducted only a few of these shifts had taken place, primarily the changes made to how Global Fund’s country teams operated, which was universally appreciated. However, we also found that much of machinery around applying for Global Fund grants remained unchanged and were not sufficiently differentiated or tailored to different country circumstances or size of grants, so continued to create bottlenecks in disease programme implementation in a number of countries.
Looking forward, we felt that the Global Fund Secretariat and Board could increase both the effectiveness and efficiency of Global Fund investments if these were more aligned to the new Sustainable Development Goals, putting even greater emphasis on support for country-driven processes, people’s right to health, health systems strengthening and sustaining national health and disease responses.
The Global Fund Board signed off on the SR2015 in November 2015. The review findings have been used in the development of the new Global Fund strategy (2017 -2021), while, again based on the findings, the TERG requested some of the team members to undertake a follow-on piece of work to examine how the Global Fund could streamline some of its funding access processes.