2.07-4.6 Global Fund Strategic Approach To HSS. WHO Report

The Global Fund Strategic Approach
to Health Systems Strengthening
Report from WHO to The Global Fund Secretariat
September 2007
47
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TABLE OF CONTENTS
Main report…………………………………………………………………………………………1
Annexes
1 July 30 - 31 Consultation Agenda…………………………………………………..15
2 July 30 - 31 Consultation Participants…………………………………………….19
3 List of consultation core background materials;

additional reading…………………………………………………………………………….25
4 Consultation background paper 3: Major health system constraints

to improving HIV/AIDS, TB and malaria outcomes, and possible
parameters for the Global Fund's response……………………………………27
5 Consultation background paper 4: The Global Fund and health

system strengthening: a short history……………………………………………35
6 Consultation background paper 5: Experiences of the GAVI Alliance

Health System Strengthening Investment……………………………………..41
Global Fund Strategic Approach to Health Systems Strengthening
Report from WHO to The Global Fund Secretariat
1 Background
Discussion on the role of the Global Fund in funding health system strengthening (HSS)
has a long history. Its Framework Document states it will support programmes 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' (ATM). The question is therefore not whether the Global Fund invests in
strengthening health systems, but how. The Global Fund Board, at its Fifteenth Meeting,
asked the Policy and Strategy Committee to make recommendations on four questions:
the possible use and nature of parameters, of conditions and of ceilings for HSS funding,
and how HSS funds might be applied for - exclusively within disease components or, in
addition, through a separate HSS window.
The Board asked WHO to identify or convene a forum to provide input on health system
strengthening as related to the Global Fund and other partners before the Sixteenth Board
Meeting. This short paper draws on a range of knowledge and experience, especially the
July consultation convened by WHO. This consultation discussed the wider context within
which the Global Fund investments are made, and different options for each of the four
questions. It was attended by health policy makers, managers and NGO representatives
from 18 Global Fund recipient countries together with representatives from international
NGOs and foundations; bilateral agencies; global health partnerships including the GAVI
Alliance; and multilateral institutions including UNAIDS Secretariat, UNICEF and the World
Bank (55 people in total, Annex 1).
As a major health financier, and with plans to increase its funding base, The Global Fund
influences health systems both directly through the resources it provides, and more
indirectly because countries sometimes adjust their policies and practices in response to
the Global Fund approach to HSS funding, for example policies in such areas as workforce
size, the roles of health workers, cost recovery, or the role of the private sector. Moreover,
it gives signals to others through its investment decisions. The Global Fund has an evolving
business model, and new strategic initiatives such as the rolling continuation channel and
'national strategy applications' (an approach to further enable 'programmatic funding')'1
also need to be taken into account in the HSS debate. This paper however focuses on the
wider HSS context, and the four Board questions. It will be used by the Global Fund
Secretariat and the Policy and Strategy Committee to inform their own documentation and
guidance for discussions on financing of Global Fund health system strengthening activities
in preparation for the Sixteenth Board meeting.
1
See Decision Point GF/B15/DP7 : Modified Application Process for Supporting Country Programs.
1
2 The wider context
There is renewed international interest in health systems. There is increasing
realization that, while global health initiatives focused on specific health outcomes have
helped catalyse attention and action on major health problems in recent years, without
more effective health systems it will not be possible to reach and sustain agreed health
goals.
There is growing clarity on the health systems agenda. The World Bank and WHO are
working together on a framework for health system strengthening that can inform more
coherent operational support to countries.
Box 1: The six building blocks of a health system

o Good health services are those which deliver effective, safe, good quality personal and
non-personal health interventions to those that need them, when and where needed,
with minimum waste of resources.
o A well-performing health workforce is one which works in ways that are responsive,
fair and efficient to achieve the best health outcomes possible, given available resources
and circumstances. I.e. there are sufficient staff, fairly distributed; they are competent,
responsive and productive.
o A well-functioning health information system is one that ensures the production,
analysis, dissemination and use of reliable and timely information on health
determinants; health system performance and health status.
o A well-functioning health system ensures equitable access to essential medical
products and technologies of assured quality, safety, efficacy and cost-effectiveness,
and their scientifically sound and cost-effective use.
o A good health financing system raises adequate funds for health, in ways that ensure
people can use needed services, and are protected from financial catastrophe or
impoverishment associated with having to pay for them. It provides incentives for
providers and users to be efficient.
o Leadership and governance involves ensuring strategic policy frameworks exist and
are combined with effective oversight; coalition-building; regulation; attention to
system-design, and accountability.
There is support for moving away from the stale vertical versus horizontal debate to a
more 'diagonal' approach. It aims to alleviate problems which can be created by vertical
programmes while recognising a continued need for specialization of some functions. A key
message is that programmes are part of any health system, and it is impossible to scale up
services to any significant extent without a stronger system. At the same time, the
rationale for strengthening health systems is to better deliver quality health programmes
and services. This shift is beginning to lead to more interaction between programme and
systems staff in countries and in international agencies. Linked to this is the renewed call
for 'integration' of health service delivery, which is concerned with ensuring a continuum
of preventive and curative services at the point of delivery, based on an agreed set of
interventions2.
2 Integration refers to the links between different types of service; links between the community and
the formal health system; links between the public, private and voluntary sector and links between
levels of the health system - from outreach, through clinics to hospitals.
2
Box 2: A 'diagonal' approach to health system strengthening
Taking the desired health outcomes as the starting point for identifying health systems
constraints that 'stops' effective scaling up of services
Addressing health systems bottlenecks in such a way that specific health outcomes are
met while system-wide effects are achieved and other programmes also benefit
Addressing primarily health systems policy and capacity issues
Encouraging the development of national health sector strategies and plans, and
reducing investment in isolated plans for specific aspects of health systems
Robust monitoring and evaluation frameworks
Global aid architecture is in flux. The Global Fund, along with other international agencies,
has endorsed the Paris Principles of harmonization and alignment with national health
policies and systems, country ownership and accountability. These aim to reduce
duplication and transaction costs experienced by countries. If taken to their logical
conclusion, they will have a profound influence on how The Global Fund supports health
system strengthening. There are also several emerging international health system
strengthening initiatives - for example, from the UK, Norway and the joint 'Harmonization
for Health in Africa' work by the World Bank, WHO, UNICEF, the African Development Bank
and UNFPA. There are also relatively small but influential new sources of funds such as
the GAVI Alliance 'health system strengthening' window. Leaders from eight international
health organizations3 agreed in July to engage with these in a coordinated manner, to
ensure effective support to countries. Standards and processes for national health
strategies and plans are being developed. All these developments make it an important
time for the Global Fund to be clarifying its approach.
Countries eligible for Global Fund grants are diverse. An increasing number have robust
national health sector strategies, medium-term expenditure frameworks, or health
workforce development plans, but others do not. Some have relatively strong institutions,
while others are still fragile. In some the Global Fund contributes a major share of the
health budget; in others it is a much smaller player. The question is how to ensure the
Global Fund's investment approach to HSS adequately reflects this diversity; does so in
ways that reduces uncertainty and is based on clear criteria; has benefits for other health
priorities - or at least does them no harm, and stays true to its business model of being
country led, multi-stakeholder-driven innovative and results focused.
Irrespective of how the Global Fund eventually decides to fund health system
strengthening, there are some critical pre-requisites that can create an enabling
environment for building more effective health systems that the Global Fund should
support along with other players
better communication: of available evidence; of Global Fund policies and

processes
more and better technical assistance (TA) in different aspects of health
systems - including greater regional and national TA capability
political will at country level
appropriate and agreed indicators to track progress in health system
performance
3
Gates Foundation; Global Fund; GAVI; World Bank; WHO; UNAIDS; UNFPA; UNICEF
3
These are discussed in more depth in section 7. The four questions posed by the Board
can be looked at from two points of view: funder and applicant. During consultation it
became increasingly evident that the questions on parameters, conditions and ceilings are
inter-linked.
3 Parameters for 'allowable HSS activities'
Purpose and options

Explicit parameters for 'allowable HSS activities' are one way of giving greater
clarity to what can be funded by the Global Fund. Some parameters already exist:
Activities must clearly contribute to "help health systems overcome constraints

to the achievement of [ATM] outcomes".
Activities that are catalytic in nature are allowable.
Major infrastructure investment is excluded.
The lack of more specific guidance has caused some difficulties for countries when
preparing proposals and some Board constituencies have had concerns over
'mandate creep'.
Additional parameters can be set in different ways. For example,

As a set of health system thematic or focus areas that reflect the biggest
constraints-to improving ATM outcomes e.g. health workforce development;
procurement and supply management systems
Based on a particular level of the system e.g. facility or district level
By defining excluded activities more explicitly
Based on the scope or scale of a proposed activity
Experience with different options, their pros and cons

There are consistent messages on the biggest health system constraints to
improved HIV/AIDS, TB and malaria outputs and outcomes, from different sources:
from countries' analyses, from The Global Fund's analyses of problems with grant
implementation, and from an increasing number of international reviews of health
system constraints to achieving the different health MDGs:
health workforce
drug and other commodities procurement and distribution systems
diagnostic services
access - especially financial access
management and coordination
reporting and monitoring
Experience suggests that while certain constraints are common, it is risky to define
focus areas too rigidly, because priorities differ across countries.
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Box 1 Top health system bottlenecks to improved ATM outcomes in six countries
Biggest
Vietnam Laos Thailand Indonesia Nepal Philippines
bottlenecks
Surveillance,
M&E system Governance HRH Coordination Coordination
1 M&E system
Information
Collaboration Coordination Coordination Policy & planning HRH
2 system
Information Surveillance
HRH Local planning HRH HRH
3 system system
Source: Identified by participants in Round 7 AAAH workshop, Thailand
The main categories of health system related activities supported by the Global
Fund reflect the major groups of constraints. However, a review of the nature of
activities within these categories is informative. For example, the chart in box 2
comes from a review of 98 approved proposals in 21 countries. Within the 'human
resources and training' category, the great majority of activities were training
related. Few proposals had recruitment or remuneration related activities. In
terms of target groups for training, analysis showed that over 80% were directed
at clinical training for health care workers and community health workers and 14%
at training in procurement and supply management.
Box 2: Human resources: the nature of activities supported by the Global Fund
Hum an r e s our ce s : br e ak dow n of activitie s
N um ber o f ac tiv it ies

0 100 200 300 400 500 600
T raining
M anagem ent/planning
T raining m aterials &

guidelines
R ec ruitm ent
R em uneratio n
Other*
Source: Review of 98 approved proposals by WHO, 2006
The key problem seems to be less the lack of more specific parameters and more
that many proposals still contain actions that are vague, and proposed in isolation
from the wider health system. This makes it difficult to judge the extent to which
the mix of activities proposed constitute or are part of a balanced package of
interventions that fit with national policy and strategy in the country concerned.
It also makes it hard to judge the extent to which proposed activities are likely to
contribute to sustained improvements across services and outcomes.
A strength of the Global Fund's business model is that it is prepared to fund

technically sound and well-justified proposals. This has allowed some countries to
secure funds for a critical constraint to scaling up ATM outputs, where the solutions
lie outside a programme's direct responsibility - Afghanistan, Malawi and Rwanda
are good examples (e.g. the Afghanistan Round 2 integrated grant aimed to build
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the capability of the Ministry of Public Health for the control of communicable
diseases by supporting managerial and administrative capacity building and
infrastructure development necessary for developing and supporting disease-
specific programmes).
Box 3 New GAVI HSS window takes a mixed and flexible approach.
The GAVI HSS window uses the same basic parameter for allowable HSS activities as the
Global Fund - it will fund actions that address health system bottlenecks to increased and
sustained high immunization coverage. However, in addition, it indicates three priority areas
in its guidelines, based on common constraints (health workforce mobilization, distribution
and motivation; supply, distribution and maintenance systems for primary health care;
organization and management of health services at district level and below). It stresses these
are not exclusive, and other areas can be funded as long as the link to improved
immunization coverage is made. Experience is positive so far, but the HSS window is still
very new. So far, 16 out of 31 HSS proposals submitted have been approved.
An alternative to defining parameters more tightly is to provide examples of

allowable activities. This too has its pros and cons. Examples can clarify what is
allowable, but at the same time increase the risk of 'copy cat' proposals, and may
limit innovation - which is a key aim of the Global Fund.
Main messages from the WHO consultation process
The parameters for allowable HSS activities should remain broad. The most
important parameter is activities that improve ATM outcomes, as identified
above. Otherwise there is a strong view that there should be few prescriptions.
Flexibility is key because of country diversity, and because it helps encourage
innovation.
However, some greater clarity on exclusions might be useful.
There are implications for partners of a broad parameters approach:

o Better guidance is needed…but no blueprints.
o Co-operation / coordination among partners is very important, to ensure
most effective use of all available funds
o Funding for TA for proposal development and implementation is essential
o Partners need to strengthen capacity to deliver relevant TA for health
system strengthening - both for proposal development and implementation
"the Global Fund should retain the principle of 'give us a good plan and a good
justification and we'll fund it' "
— quote from participant at the July consultation
4 The possible use and nature of conditionality for applying for HSS funding
Purpose and options

Conditions can be used for different purposes. They can provide guidance to help
promote investment, to create an incentive for important pre-requisites for
successful HSS funding (e.g. incentive to have a good national health plan), or
they can be used to restrict entry and control access to funds. They are closely
6
related to parameters - indeed some use the terms inter-changeably. Conditions
can be loose (such as demonstrating a link to ATM outputs and outcomes) or rigid
(no national strategy, no funds). They may be designed to encourage certain
processes or products deemed desirable - for example the pursuit of greater equity
in service delivery; the participation of relevant stakeholders; essential
interventions to be included. Conditions could be designed to reinforce features of
the Global Fund's business model: for example, to catalyse change. Conditions
may take different forms - guidance or fixed rules.
Experience with different options, their pros and cons

Experience suggests that conditions in the conventional sense don't work. There
has been a move away from standard conditions set by a financing institution and
applied to all countries, towards agreements negotiated with recipients on an
individual basis. The language is changing. In the consultations there was much
more support for the notion of a set of pre-requisites or principles. GAVI's
'principles' are a form of conditionality, to encourage good practice in proposal
development. The need for mutual accountability rather than one-way conditions
was also raised.
All conditions, even supposedly positive ones, have their pros and cons. For
example, well intended but inflexible conditions such as 'no strategic plan, no
funding', or matching funds, might penalise weaker, poorer health systems.
However, linking a grant to initiation of the development of a country health
workforce strategy could be positive. Complex conditions would have high
transaction costs for all concerned. Conditions on process can be useful, but can
also be labour intensive as they take a special effort on the part of countries and
proposal review teams to make them work in practice.
Box 4 Can conditions support effective health system strengthening?

thoughts from Kenya TB programme
Yes, if this encourages HSS proposals to
Link with overall health sector development policy and strategies
Focus on delivering an essential package of care that includes ATM, through
both public and private providers
Focus on lower levels of the health system
Yes, if the proposal development process leads to

A critical assessment of health system constraints, and needs
A critical evaluation of a country's political commitment
The promotion of programme ownership by stakeholders, including those
outside the health sector
The fact that the Global Fund is planning to substantially increase in size, and that
other global financing institutions are changing, makes the discussion of conditions
important.
Main messages
The fewer conditions the better, but countries need to know what is expected.
Guidance is needed and wanted.
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One size cannot fit all. Flexibility is essential.
Any conditions should be simple, clearly communicated and have transaction

costs proportionate to their benefits.
Proposals should be more clearly aligned with (i.e. show how they contribute
to) national health development plans, medium term expenditure frameworks
(MTEFs) and Poverty Reduction Strategy Papers (PRSPs).
Conditions should apply to private sector and civil society organizations as well
as public sector institutions.
The Global Fund is a partnership. Mutual accountability is important.
There are some pre-conditions that seem widely acceptable, shown in box 5
Box 5: Acceptable pre-conditions
o Proposals should be based on a sound analysis of HSS constraints to improved ATM

outputs and outcomes.
o Proposals should be linked to ATM service outputs and outcomes, (and possibly MDG
targets)
o Proposals should provide evidence of commitment to and alignment with the health
sector plan or strategy. Guidance on how to ensure consistency with national plans
would be useful, providing they are simple and clear
o Proposed HSS actions should be based on best available evidence of what works and
what does not.
o Proposals should provide evidence of involvement of relevant stakeholders beyond a

programme and possibly beyond the health sector, in both proposal development
and implementation oversight
While many of these suggested 'conditions' are not new to the Global Fund, they
have been strongly and frequently recommended during the consultation process.
Like the parameters discussion, they have implications for support from partners;
for countries and for Global Fund structures, guidelines and procedures.
5 The possible use and nature of ceilings for HSS funding
Purpose and options

Financial ceilings would set a limit on the Global Fund's investments in HSS. Behind
this question is a concern about responsible risk management. Ceilings could help
keep a focus on the Global Fund's mandate and manage the 'bottomless pit'
concern often voiced in discussions on health systems investment. They could
reinforce the point that the Global Fund is only one of many financiers in HSS.
Currently, the GFATM does not have ceilings for disease specific applications, and
they are only being considered if there is a separate HSS window.
Financial ceilings can be set in different ways: as a global 'pot' of funds (setting
aside a fixed sum over a certain time frame) and / or on a country specific basis.
Global ceilings address the 'bottomless pit' concern, but raise questions about how
to manage applications for funds. Country ceilings could be set using a formula (for
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example, population, income or need), but this would need to be very simple to be
workable, and to be seen as fair across different types of countries. Country
ceilings might help encourage a broad spread of activities and country coverage, as
they provide a measure of predictability. Ceilings could be set in absolute terms
or as a percentage - of a specific grant, or of overall funding. Alternatively there
could be no ceiling, with the maximum determined by the quality of the proposal
alone. The nature of the activity to be funded is another way to think about
ceilings: the cost of relaxing specific health system constraints may be relatively
modest and is quite different from embarking on financing the health system as a
whole. Any policy on ceilings would need to be reviewed after a period. Finally,
there is the option of having a 'floor' rather than a ceiling, as one way for the
Global Fund to encourage actions on major health system constraints.
Experience with ceilings, and their pro's and cons

Ceilings serve to reassure cautious investors, and can be part of a 'learning by
doing' approach. However, ceilings are difficult to manage well. Ceilings do not
easily reflect other considerations such as country absorption capacity or funding
from other donors. There are other ways to achieve at least some of their aims.
For example, by taking account of national plans and other donor investments in a
country, when assessing financial support.
Box 6: The GAVI HSS window and its experience with ceilings
In its decision in December 2005, the GAVI Board approved an initial global ceiling of
USD500 million for 2006 - 2010, with an evaluation in 2010 and an overall time horizon of
2015. It also approved that country specific budget envelopes would be determined by a
formula based on GNI per capita and the number of newborns per year. There are some
concerns about the value and fairness of this formula for very small and very large population
countries. USD266 million out of USD500 million have been approved by the Independent
Review Committee for 16 of the 29 countries that have applied so far. Approximately 40
more have indicated they are likely to apply in the next round later this year. The Board will
discuss forecasted funding requirements for this GAVI HSS window at its next meeting.
There are some differences between GAVI and the Global Fund when considering
options for ceilings. The Global Fund's mandate for three diseases makes country
specific formulae harder to set in ways that make sense and would be fair. The
Global Fund already has an established track record in financing HSS activities4
where the case is thought well-argued. Moreover, its experience is that national
CCMs behave responsibly and are generally unlikely to let through unreasonably
large HSS proposals.
Does HSS really run the risk of being a 'bottomless pit' of expenditure?. More work
is needed - signalled in section 7. However, experience suggests that with the
possible exception of infrastructure, many of the interventions needed to address
specific system constraints (as opposed to financing the system as a whole) are
relatively inexpensive. For example, improved coordination, planning and
management capacity, supervision, or improved equipment maintenance systems
are not generally high cost activities. What may be more important than money is
support to create momentum for action. Here the Global Fund can help leverage
4
See table 6 in July consultation background paper 3
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significant change with rather small investment. To give one example, in Ethiopia
large Global Fund grants for drugs and commodities overwhelmed the national
pharmaceutical supply service (PASS). This was used by the MOH as an
opportunity to accelerate improved procedures in PASS, with only a small amount
of funds needed for great effect.
The bottom line is that ceilings provide certainty for the Global Fund, but may
constrain applicants. And ceilings could risk sending a conflicting message about
The Global Fund, for whom a key objective is significant scale-up of ATM
programmes.
Main messages
Avoid ceilings. Where the concern is about salary costs, it is better to say this
upfront and negotiate country specific strategies.
The use of an 'HSS floor', possibly as a percentage of any grant, might be

more useful to help promote the desired 'diagonal' approach, but needs further
exploration
6 Pulling it together: modalities for supporting HSS
Purpose
The first three questions addressed here - on parameters, conditions and ceilings -
are all part of the same debate over Global Fund policy: how to improve the
Global Fund's support for HSS in diverse countries while responsibly managing
risks for both the Global Fund itself and countries. The fourth question has more to
do with internal Global Fund procedures: whether or not to have a separate
window for HSS (in addition to funding HSS within disease-specific components).
Options and experience

There are good and bad experiences in preparing successful proposals with and
without a separate window. The TRP's experience with low quality stand alone HSS
applications - whether it is called a cross-cutting, integrated or HSS component, is
well-documented. Round 6 experience, in which health system strategic actions
were located within disease components is also important here: the TRP noted that
the quality of proposed HSS strategic actions was no higher in round 6 than in
round 5. It seems other factors affect proposal quality.
The main argument deployed for keeping HSS within a disease component is that
programmes are part of systems and it is artificial to separate the two. The
practical problem with having HSS within a disease component application is to
do with the process by which proposals are developed. If the process continues to
be seen as largely the province of an individual programme and its more disease-
focused partners, then few will address health system constraints in a truly
systemic way, and the risk of unintended, unwanted repercussions on other
programmes and services will be greater. It is not easy to do this differently but it
is possible even within current Global Fund arrangements, as was illustrated by the
Kenya TB programme in the July consultation. Another argument in favour of
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integrating HSS activities within disease components is that it makes the proposal
development process simpler, meaning less work for countries, while still
remaining sufficiently flexible.
The main arguments deployed for having a separate HSS component are that
there are more opportunities for 'integration'; that it is the only way to initiate
truly system-wide action; that it is an additional way of signalling the Global Fund's
support for HSS, and might make it easier to mobilise HSS technical support. The
main practical problems with having a separate HSS component are to do with
judging what goes into that component versus a disease component, and the
creation of yet another application channel. Indeed, an interesting suggestion was
made in the July consultation that it might be helpful to reduce the number of
application channels from three to one, rather than increase them from three to
four. This was not discussed in any detail, but merits consideration.
Main messages
The Global Fund should support programme based approaches where possible.
Where Global Fund specific proposals are needed, opinion remains divided
on whether countries should be asked to apply for HSS funds through disease
specific components only, or in addition through a separate HSS component.
The idea of reintroduction of a 'cross-cutting' component has some traction. It
may be especially important for fragile states with very weak health systems,
and for activities that don't fit well within disease programmes.
What seems more important to enhance the Global Fund's role in HSS than the
question of what sort of application window is the question of technical
support. More and better support is needed in proposal development to bring
together ATM and HSS perspectives and key national players, and afterwards
during implementation.
Whatever modality of support is decided upon by the Board, good indicators

for tracking changes in health system performance are needed.
7 Summary and implications for different stakeholders

The discussion on parameters, conditions and ceilings is all really part of the same debate:
how can the Global Fund best invest in HSS in order to improve ATM outcomes?
Underpinning the discussions has been a recognition of country diversity; a need to retain
the Global Fund's emphasis on innovation and on results. There was support for the
principle of 'integration' of service delivery where possible that allows delivery of ATM
services as part of an essential package of care - and for developing a more 'diagonal
approach' to HSS that brings programme and systems experts together.
The main messages around the four questions can be summed up as follows
Retain flexibility. Keep the parameters for ‘allowable HSS activities’ as broad as
possible (perhaps only indicating major exclusions); keep conditions as loose
as possible; avoid ceilings. There is a set of pre-conditions to build on that are
widely acceptable. They are not new to the Global Fund but would benefit from
more clarity, visibility and support.
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Guidance is needed and wanted both on the Global Fund rules and conditions,
and on how to assess and address health system constraints, to reduce
uncertainty. This should be clear and simple.
The question of an HSS window is a procedural not a policy question. Opinion

remains divided. The window question becomes less important if key aspects of
the enabling environment are addressed: better access to information; access
to the right sort of technical assistance, and procedures that further encourage
a 'diagonal approach'.
Consideration should be given to the possible implications of any decisions for

Global Fund architecture, processes and capacity at global and country level.
For example, the structure of the TRP; guidance to CCMs, indicators for
monitoring performance.
Irrespective of the Board's decision on any of the specific questions, fostering

an enabling environment is key to improving the Global Fund's role in HSS
Main messages about the enabling environment: implications for countries, the Global
Fund, and other partners.
1. Better access to information

This was a recurring theme. Two sorts of information are required. Information on the
Global Fund's own rules and procedures. Second, access to best available evidence on
effective HSS interventions, on costs and on experience with good strategy design.
A clear message was that information on the Global Fund's website is useful but not
sufficient. The July consultation was a very valuable communication exercise in its own
right. Other opportunities to allow stakeholders to discuss issues in a technical and
supportive way need to be encouraged.
Technical agencies need to help improve access to evidence. Knowledge is increasing

but it could be made more readily accessible.
2. Better technical assistance for health system strengthening

More and better TA is needed, especially if the parameters for 'allowable HSS activities'
remain broad. Proposals are only a beginning, and good proposals do not automatically
translate into better services. Funding for TA for proposal development and also for
implementation is essential. There is a need to move beyond ad hoc individual,
'project' specific consultancies identified at short notice to a more strategic approach in
which appropriate TA is available; reflects local needs, and is used. Other organizations
such as GAVI are also struggling with this and there is room for more coordinated
approaches. Regional and national TA capabilities need to be strengthened.
3. More coordination and co-operation at country level

The Global Fund is too big a player to operate on its own. Broad parameters and loose
conditions means co-operation and coordination among partners is very important, to
ensure most effective use of all available funds. There is also a need to enable greater
collaboration across systems and programme management authorities in countries.
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4. The importance of political will at country level, to steer and sustain efforts when
almost inevitable difficulties are encountered in implementation
5. Greater mutual accountability
6. Credible indicators for tracking health system performance.

The Global Fund is already part of work led by WHO and the Health Metrics Network to
develop a health system metrics dashboard for monitoring trends in health system
performance - including trends in equity, which many information systems neglect to
report on. This is being piloted in Tanzania. Additional suggestions made during the
consultation will be shared with the group working on the dashboard.
13
14
Annex 1
Global Fund Strategic Approach to Health Systems Strengthening

DAY 1
0800 - 0900 Registration
0900 - 0930 Session 1

Welcome, background and purpose of the consultation
Background, scope and purpose: The fifteenth GFATM Board meeting decided that the
Global Fund's strategic approach to health system strengthening is 'investing in activities
to help health systems overcome constraints to the achievement of improved outcomes for
HIV/AIDS, TB and malaria'. The question is therefore not whether the GF invests, but how.
The GF Board identified four questions to be addressed. It also requested that WHO
convene a forum to provide input on health system strengthening as related to the Global
Fund and other partners, before the Sixteenth Board meeting.
This session will recap the GF mandate. It will set out the 4 questions, and clarify meeting
objectives, process and products.
Overview of background and purpose of consultation

Hiro Nakatani, 5 minutes
Plenary discussion: clarifications only
Introduction of participants and handover to meeting Chair
0930 - 1030 Session 2 part 1

The health systems agenda: global developments and country
perspectives
Background and scope: The aim of this session is to set the broader and evolving
context within which the GFATM Board's specific questions are to be discussed. It will
briefly review the accelerating international focus on strengthening health systems;
emerging clarity on the health system strengthening agenda, funding needs, and on roles
of different players; the current status of national sector strategies, medium term
expenditure frameworks; and approaches to monitoring health system performance. Two
country perspectives will reflect on how all this is being translated at country level.
Overview of global developments: Anders Nordstrom, 15 minutes

Two country perspectives: 5-7 minutes each
Caroline Kayonga; Aynura Ibraimova
Plenary discussion
1030 - 1100 BREAK
1100 - 1230 Session 2 part 2

Plenary discussion continued
1230 - 1330 LUNCH
1330 - 1500 Session 3 part 1
15
Parameters for defining priority areas for GF funding of health
system strengthening activities
Background and scope: The aim of this session is to address the first of the four
questions posed by the GFATM Board. Parameters for allowable HSS investments can be
set in a number of different ways. The challenge is to frame GFATM parameters in ways
that are sufficiently flexible to respond to different country needs, but also provide
sufficient direction to reduce the confusion and uncertainty experienced by countries, the
TRP and the Board. The session will review the biggest health system constraints faced by
HIV, TB, and malaria. It will summarize GFATM experience across the seven rounds in
defining parameters for investment to overcome these constraints, and how these have
worked at country level. It will draw on GAVI experience with defining parameters for
funding. Some options for defining parameters identified so far include: defining a set of
'thematic' or focus areas; focusing on a particular level of the system; defining non-
allowable activities more clearly; having greater clarity on what it makes sense to fund on
a programme specific basis, and what through other modalities. The session will consider
these and other options, their pros and cons, and how they are likely to work in practice.
Two country perspectives will be presented.
Introduction Diana Weil, 10 minutes

Two country perspectives: 5-7 minutes each
Piya Hanvoravongchai; Hudson Nkunika
GAVI experience: Craig Burgess, 10 minutes
Plenary discussion (part 1)
1500 - 1530 BREAK
1530 - 1700 Session 3 part 2

Continued discussion in plenary
1700 Summary of day 1

Review of progress; links to and challenges for day 2
1800 COCKTAIL, WHO MAIN BUILDING RESTAURANT
DAY 2
0830 - 0840 Day 2 objectives and programme
0840 - 1000 Session 4

The possible use and nature of conditionality
Background and scope: The aim of this session is to address the question posed by the
Board on whether to attach conditions to any HSS funding. Here the term is used to mean
pre-conditions or prerequisites for application for HSS funds - beyond those already in
place. The session will consider the pros and cons of alternatives, from the perspectives of
countries and the GFATM. Issues to consider include: a need to be clear what any
conditions are for: are they to restrict entry? to provide guidance to applicants? to
facilitate spending? Second, the GFATM as a major donor has an important role in
signalling to others, and it also wants to avoid 'going backwards' in terms of its shift from
project to programme support. Third, any conditions should be as simple as possible, as
they will have implications for transaction costs for countries; for proposal development
support; for TRP processes, and for other donors. Options so far identified fall into two
broad categories: conditions to encourage greater harmonization and alignment, and -
not unrelated - conditions on proposal preparation process. Examples that have been
suggested include: proposals should show how intended actions fit with priorities in a
national health sector framework; where a country lacks an accepted and costed national
health sector strategy, health workforce development plan or costed programme plan, a
condition of obtaining GFATM funds could be that it agrees to develop these. Matching
funds is another possibility. Additional conditions on proposal preparation processes that
16
might help quality and prospects for implementation have been suggested: revised
membership of the proposal preparation team and the CCM; some more inclusive
consultation processes. In proposal review, many would argue that the spirit of any
conditions must be understood and interpreted as guidance rather than rigid rules.
Respondents will provide practical perspectives.
Introduction Brenda Killen, 5 minutes

Perspectives from two respondents 5 minutes each
Morris Edwards; Jeremiah Chakaya
Plenary discussion
1000 - 1030 BREAK
1030 - 1230 Session 5

The possible use and nature of ceilings for HSS funding
Background and scope: The aim of this session is to address the third question: whether
limits should be set on the quantity of funds that could be requested for HSS activities. As
before, this session will discuss different options, and implications from the perspectives of
different stakeholders. There are a number of issues to consider. Currently, the GFATM
does not have ceilings for disease specific applications. There are arguments for and
against ceilings. Behind the Board's question is a concern about responsible risk
management. In terms of options, the discussion on ceilings can be cast in different ways:
for example, by the nature of activity to be funded and in terms of financial limits.
Financial ceilings may be set as a global ceiling (setting aside a fixed sum over a certain
time frame) and / or on a country specific basis. GAVI does both. Global ceilings address
the 'bottomless pit' concern, but raise questions about how to manage applications for
funds. Country ceilings can be set using a formula, which must be very simple to be
workable. Financial ceilings can also be set in absolute terms or as a percentage of a
specific grant. Another suggestion is that ceilings be determined by the quality of the
proposal and past absorption capacity. Any ceilings could be reviewed after an agreed
time. The question of having a 'floor' as well as a ceiling to HSS proposals has also
been raised, as one way for the Fund to encourage actions on major health system
constraints. Respondents will provide practical perspectives.
Introduction Brenda Killen, 5 minutes

Two respondents, 5 minutes each
Wei Ran; Joy Phumaphi
Plenary
1230 - 1330 LUNCH
1330 - 1530 Session 6

Pulling things together - options for channelling GFATM
investment, and implications for GF structures and procedures
Scope: The aim of this session is to address the fourth question asked by the Board, which
concerns modalities for channelling GFATM funds for HSS. This session will take stock of
discussion in previous sessions to inform the very practical question on options for
channelling GFATM investments. A range of options exist, and the discussion will include
but not be limited to the question of whether or not to have a separate HSS component.
The implications of different alternatives, primarily from a country perspective but also
implications for GFATM structures and processes, will be considered. The session will begin
with three participants from different constituencies reflecting on discussions to date; and
considering implications for GFATM funding modalities, and associated structures and
procedures
Taking stock; looking forward: reflections (5 minutes each)

Asia Russell; Jimmy Kolker; David Mwakyusa
Plenary discussion
Half way summary of key messages emerging: Maureen Law
17
Plenary continued
1530 - 1600 BREAK
1600 - 1730 Session 7

Emerging recommendations and conclusions
Plenary, and summary by Chair
1730 - 1745 Session 8

Closure
18
Annex 2
Consultation on Global Fund Strategic Approach to Health Systems Strengthening

WHO, Geneva, 30 -31 July 2007
List of Participants
NAME & ADDRESS

Jeremiah Chakaya
Mahomed Fareed Abdullah Technical Expert
Director: Technical Support National Leprosy and TB Programme
International HIV/AIDS Alliance Ministry of Health
Queensberry House P.O. Box 30016
104 Queens Road 00202 - Nairobi
Brighton BN1 3XF Kenya
United Kingdom chakaya@todays.co.ke
fabdullah@aidsalliance.org
Morris Edwards
Eddie Addai Deputy Programme Manager
Director Policy Planning, Monitoring and Principal Recipient
Evaluation and Co-Chair of Strategic CARICOM Secretariat
Partnership with Africa Turkeyen
Ministry of Health Greater Georgetown
P.O. Box M44 Guyana
Accra medwards@caricom.org
Ghana
eddieaddai@yahoo.co.uk Norbert Forster
Under Secretary: Health and Social
Anshu Banerjee Welfare Policy
Senior Programme Officer Ministry of Health and Social Services
Country Support Team Private Bag 13198
GAVI Alliance Secretariat Windhoek
c/o UNICEF Namibia
Palais des Nations undersec@healthnet.org.na
CH-1211 Geneva 10 nforster@mhss.gov.na
Switzerland
abanerjee@gavialliance.org Eric A. Friedman
Senior Global Health Policy Advisor
Karlo Boras Physicians for Human Rights
th
Member of Developing Country NGO 1156 15 Street, NW, Suite 1001
Delegation on Global Fund Board Washington, DC 20005
JAZAS United States
27. marta 35 efriedman@phrusa.org
11000 Belgrade
Serbia Paulo Ivo Garrido
karlo.boras@jazas.org.yu Minister of Health
Ministry of Health
Martien Borgdorff Ave Eduardo Mondlane
Executive Director N 1008 Maputo
KNCV Tuberculosis Foundation Mozambique
PO Box 146 pigarrido@misau.gov.mz
Parkstraat 17 (Hofstaete Building)
2514 JD - The Hague Peter Godfrey-Faussett
The Netherlands TRP Chair
borgdorffM@kncvtbc.nl London School of Hygiene and Tropical
Medicine
Craig Burgess Department of Infectious and Tropical
Senior Programme Officer Diseases
Health Systems Strengthening LSHTM, Keppel Street
GAVI Alliance Secretariat London WC1E 7HT,
c/o UNICEF, Palais des Nations United Kingdom
CH-1211 Geneva 10 Peter.Godfrey-Faussett@lshtm.ac.uk
Switzerland
cburgess@gavialliance.org
19
Deepak Gupta Ambassador Jimmy Kolker
Additional Secretary Deputy U.S. Global AIDS Coordinator
Ministry of Health Department of State
Government of India S/GAC SA-29, 2nd Floor
Nirman Bhavan 2201 C. Street NW
New Delhi 110 011 Washington, DC 20522-2922
India United States
dgupta51@rediffmail.com kolkerjj@state.gov
asdg-mohfw@nic.in
Gilbert Kombe
Piya Hanvoravongchai Senior HIV/AIDS Technical Advisor
Coordinator 4800 Montgomery Lane, Suite 600
Asia-Pacific Action Alliance on Human Bethesda, MD 20148
Resources for Health United States
IHPP-Thailand Gilbert_Kombe@abtassoc.com
Ministry of Public Health
Sataranasuk 6 Road Joep Lange
Nonthaburi Province 11000 Professor of Medicine
Thailand Center for Poverty-related
coordinator@aaahrh.org Communicable Diseases
Academic Medical Center
Lennarth Hjelmåker University of Amsterdam-T125
Ambassador - HIV/AIDS Matters Meibergdreef 9
Ministry of Foreign Affairs 1105 AZ Amsterdam
SE-10339 Stockholm The Netherlands
Sweden j.lange@amc.uva.nl
lennarth.hjelmaker@foreign.ministry.se
Maureen Law
Cassia van der Hoof Holstein Suite 4C
Director, Rural Health 268 First Ave.
William J. Clinton Foundation HIV/AIDS Ottawa ON K1S 2G8
Initiative Canada
55 West 125th Street mlaw@ca.inter.net
New York, NY 10027
cassia@clintonfundation.org Gabriele Mallapaty
Senior Advisor
Ainura Ibraimova Health Systems Strengthening
Deputy Minister of Health UNICEF
General Director of the Mandatory Three United Nations Plaza
Health Insurance Fund New York, New York 10017
122, Chui ar USA
Bishkek 720040 gmallapaty@unicef.org
Kyrgyz Republic
a_ibraimova@foms.med.kg Shaun Mellors
Senior Technical Advisor
Jantine Jacobi Civil Society Development
Senior Adviser, Country Support for International HIV/AIDS Alliance
Treatment and Care Queensberry House
20 Avenue Appia, 104-106 Queens Road
CH-1211 Geneva Brighton BN1 3XF
jacobij@unaids.org United Kingdom
smellors@aidsalliance.org
Caroline Kayonga
Permanent Secretary Vincent Musowe
Ministry of Health Policy and Technical Advisor to
P.O. Box 84 Permanent Secretary
Kigali Ministry of Health
Rwanda PO Box 30205
ckrwiva@yahoo.com Lusaka
Zambie
Musowe@zamtel.zm
Musowevincent@yahoo.co.uk
20
Mr Simon Mphuka Bob Pond
Executive Director Health Metrics Network
Church Health Association of Zambia World Health Organization
Ben Bella Road 20, avenue Appia
P.O Box 34511 CH-1211 Geneva
Lusaka pondb@who.int
Zambia
mphuka@zamnet.zm Carole Presern
Counsellor (Specialised Agencies/
David Mwakyusa Development)
Minister for Health United Kingdom Mission to the UN
Ministry of Health 37-39 Rue de Vermont
P.O. Box 9803 1211 Geneva 20
Dar-es-salaam carole.presern@fco.gov.uk
Tanzania
dmwakyusa@moh.go.tz Wei Ran
Senior Program Officer
Francoise Ndayishimiye Division of International Organizations
Secrétaire Exécutif Permanent du Department of International
Conseil National de lutte contre le SIDA Cooperation
Board Member in the GFATM in the Ministry of Health
Communities Delegation P.R China 100044
Chausée Prince Louis Rwagasore, weiran@chinaaids.cn
Immeuble de la Banque de la ZEP
BP 816 Asia Russell
Bujumbura Director International Relations, Health
Burundi Gap
francnd@yahoo.co.uk 4951 Catherine Street
Philadelphia, PA 19143
Hudson Z. Nkunika USA
Health Systems Strengthening asia@healthgap.org
Coordinator and HSS Desk Officer for
Global Fund Lars-H. Selwig
Ministry of Health Headquarters First Secretary
P. O. Box 30377 Development Policy
Lilongwe 3 Permanent Mission of Germany
Malawi 28c, chemin du Petit-Saconnex
mchukuchuku@yahoo.co.uk CH-1209 Geneva
lars.selwig@diplo.de
Francis Omaswa
Executive Director Stephanie Simmonds
Global Health Workforce Alliance Member GFATM Technical Review
(HWA) Panel (TRP)
World Health Organization Mejlijina 8, Stari Grad
20, avenue Appia 71000 Sarajevo
Ch-1211 Bosnia-Herzegovina
Geneva 27 sarajevohospice@yahoo.com
omaswaf@who.int
Krista Thompson
Gorik Ooms Vice President
Executive Director General Manager, Global Health
Médecins Sans Frontiéres Belgium BD (Becton, Dickinson & Company)
Rue Dupré 94 Becton Drive
1090 Brussels Franklin Lakes, NJ 07417
Belgium USA
gorik.ooms@brussels.msf.be krista_thompson@bd.com
Joy Phumaphi
Vice President Human Development
The World Bank
1776 G Street NW
Washington, DC 20433
United States
jphumaphi@worldbank.org
21
Wim Van Damme Nata Menabde
Professor in Public Health Deputy Regional Director
Institute of Tropical Medicine World Health Organization
Nationalestraat 155 Regional Office for Europe
2000 Antwerp Copenhagen, Denmark
Belgium nme@euro.who.int
WVDamme@itg.be
Rufaro Chatora
Sayad Shukrullah Wahidi Director, Aids, Tuberculosis and
Director-General Policy and Planning Malaria
Ministry of Public Health World Health Organization
Kabul, Afghanistan Regional Office for Africa
c/o WHO, Kabul, Afghanistan B.P. 6
wahidi2uk@yahoo.com Brazzaville
Republic of Congo
Francisco Yepes chatorar@afro.who.int
Executive Director
Colombian Health Association Subhash Salunke
(Asociación Colombiana de la Salud – The WHO Representative-Indonesia
ASSALUD) PO Box 1302
Carrera 13 # 32-51- Office 918 Jakarta 10350
Bogota Indonesia
Colombia salunkes@who.or.id
franciscoy@cable.net.co
assalud@cable.net.co Brenda Killen
Coordinator
Mamadi Yilla Health Policy Development & Services
Senior Policy Advisor Services
HIV/AIDS Interagency Coordinator, Killenb@who.int
PEPFAR
United States Embassy Phyllida Travis
Lilongwe Health Systems Adviser
Malawi Health Policy Development & Services
yillam@state.gov travisp@who.int
Paul Zeitz Diana Weil

Executive Director Senior Policy Adviser
Global AIDS Alliance Stop TB Department
1413 K Street NW, 4th Floor weild@who.int
Washington, DC 20005
USA Andrew Ball
pzeitz@globalaidsalliance.org Senior Strategy and Operations Adviser
Department of HIV/AIDS
WHO Secretariat balla@who.int
Hiroki Nakatani
Assistant Director-General Badara Samb
HIV/AIDS, Tuberculosis and Malaria Acting Coordinator
nakatanih@who.int Systems Strengthening and HIV (SSH)
sambb@who.int
Anders Nordstrom
Assistant Director-General
Health Systems and Services
nordstroma@who.int
Denis Aitken
Representative of the Director-General
Partnerships and UN Reform
aitkend@who.int
Winnie Mpanju-Shumbusho
Senior Adviser to the Assistant Director-
General
HIV/AIDS, TB and Malaria
mpanjuw@who.int
22
Global Fund Secretariat Observers
Helen Evans Enrico Vicenti/Lucie Tagliaferri

Deputy Executive Director Permanent Mission of Italy to the United
The Global Fund to Fight AIDS, Nations
Tuberculosis & Malaria Chemin de l'Imperatrice 10
Helen.Evans@TheGlobalFund.org 1293 Geneva
Enrico.Vicenti@esteri.it
Stefano Lazzari
Senior Health Advisor Kevin De Cock
The Global Fund to Fight AIDS, Director
Tuberculosis & Malaria HIV Department
Stefano.Lazzari@TheGlobalFund.org World Health Organization
decockk@who.int
Nosa Orobaton
Director Of Operations Teguest Guerma
The Global Fund to Fight AIDS, Associate Director
Tuberculosis & Malaria HIV Department
Nosa.Orobaton@TheGlobalFund.org World Health Organization
guermat@who.int
David Salinas
Manager, Business Strategy Mario Raviglione
The Global Fund to Fight AIDS, Director
Tuberculosis & Malaria Stop TB Department
David.Salinas@TheGlobalFund.Org World Health Organization
raviglionem@who.int
Ian Grubb
Adviser to Executive Director Sergio Spinaci
The Global Fund to Fight AIDS, Associate Director
Tuberculosis & Malaria Global Malaria Programme
Ian.Grubb@TheGlobalFund.org World Health Organization
spinacis@who.int
Karmen Bennett
Manager, Proposals Advisory Services Awa Maria Coll-Seck
The Global Fund to Fight AIDS, Executive Director
Tuberculosis & Malaria Roll Back Malaria Partnership
Karmen.Bennett@TheGlobalFund.org Secretariat (RBM)
World Health Organization
Johannes Hunger collsecka@who.int
The Global Fund to Fight AIDS,
Tuberculosis & Malaria Marcos Espinal
Johannes.Hunger@TheGlobalFund.org Director
Stop TB Partnership Secretariat (TBP)
espinalm@who.int
Jorge Bermudez
Executive Secretary
UNITAID International drug purchase
facility (UTD)
bermudezj@who.int
Rania Kawar
Technical Office
Heath Systems Strengthening
Kawarr@who.int
23
24
Annex 3
List of background materials
A Core materials
Background note 1 Decision point GV/B15/DP6: Global Fund strategic

approach to health systems strengthening
Background note 2 Everybody's Business. Strengthening health systems

to improve health outcomes, WHO 2007
Background note 3 Major health system constraints to improving

HIV/AIDS, TB and malaria outcomes, and possible parameters for the
Global Fund's response
Background paper 4: The Global Fund and health system strengthening: a

short history
Background paper 5 Experiences of the GAVI Alliance Health System

Strengthening Investment
B Additional background reading
Can be found on the following web page:
http://www.who.int/healthsystems/upcoming/en/index.html
25
26
Annex 4
The Global Fund's Strategic Approach To Health System Strengthening
Background note 3, July 30 - 31 2007 Consultation
Major health system constraints to improving HIV/AIDS, TB and malaria

outcomes, and possible parameters for the Global Fund's response
Introduction
Debate on parameters for allowable health system strengthening (HSS) funding by the
Global Fund has a long history. For this consultation it needs to be grounded in a
common understanding of the major health system constraints that countries face in
improving HIV/AIDS, TB and malaria outputs and outcomes. It needs to be underpinned
by a recognition that the Global Fund can influence the development of health systems
and services in two basic ways: through direct funding, and more indirectly through its
impact on government policies such as cost recovery; the size of the workforce; the roles
of different health workers; the role of the private sector etc. Both are important. This
consultation is primarily about direct investment, but needs to take the Global Fund's
indirect role, which is often overlooked, into account. Discussion also needs to take
account of the diversity of countries eligible for Global Fund support.
This note is organised in three parts. First, it provides an overview of the biggest health
system constraints or 'bottlenecks' faced by the three diseases. Second, it summarizes the
nature of actions that are being supported by the Global Fund to overcome these
constraints. Third, it sets out some options for defining appropriate parameters for Global
Fund HSS investments, to stimulate discussion.
1. What are the biggest health system constraints to improved HIVAIDS,

TB and malaria outputs and outcomes?
In any health system, good health services are those which deliver effective, safe, good
quality prevention and treatment to those that need it, when needed, with minimum
waste of resources. Effective delivery of HIV/AIDS, TB and malaria interventions
requires staff with the appropriate knowledge and skills, plus medicines, diagnostics and
equipment, working in an environment that provides the right incentives to providers
and the population.
There are fairly consistent messages on the biggest constraints to improved HIV/AIDS,
TB and malaria outputs and outcomes, from many different sources.
One source is the Fund's own analyses of problems with grant implementation. The
constraints listed in box 1 have been identified as a common source of problems:
Box 1 GFATM grant implementation problems due to health system constraints

health workforce mobilization, payment and management
local management capacity in general, especially financial management
infrastructure and equipment maintenance capacity
monitoring and evaluation systems
supply chain management
financing mechanisms that constrain access or create impoverishment
high level management capacity: for overall sector policy development; to
manage multiple partners; manage relations with non health sector actors
source: Background document: Health System Strengthening; 3rd Portfolio Committee Meeting, 2006
A second source is countries' own perceptions of their greatest health system constraints
to addressing HIV/AIDS TB and malaria. The diagram below provides an indication.
27
Box 2 Country priorities as articulated in 30 HSS proposals s in GFATM round 5
Human Resources
Information Systems Development
Facility, Lab & Equipment Upgrade
Management Strengthening
Institutional Strengthening
Procurement & Supply Systems
Improved Access (Non-Financial)
Private Sector Involvement
Improved Access (Financial)
Community Capacity for Care
Transport / Communications
0 5 10 15 20
Source: WHO, 2006
These findings are echoed in an increasing number of international reviews of health

system constraints to achieving the different health MDGs, and in additional discussions
prior to this meeting. All agree more resources alone are not enough. A second key
message is that similar health system constraints are encountered by almost every major
health priority. For HIV/AIDS, TB and malaria, the repeated messages from multiple
sources about the biggest and commonest constraints are summarised in box 3.
Box 3: Summary of the biggest constraints for HIVAIDS, TB, malaria

Availability, skills and motivation of health workers
Drug procurement and distribution systems
Diagnostic services
Access - especially financial access
Management and coordination of services
Information and monitoring systems
The relative importance and particular nature of a constraint will of course vary country
by country. Applicants for funds have always been asked to identify programme needs,
gaps and health system capacity in their proposals, but the request for an analysis of
health system constraints is most explicit in the guidelines for round 7. Feedback on how
this has worked should be available in the next few weeks.
2. Actions to overcome HSS constraints already supported by the Fund

Within any of the broad thematic areas listed above, some constraints can be resolved by
intervention at the service delivery level, while others can only be resolved by actions at
higher levels of the system. Some can be addressed on a programme specific basis while
others would benefit from greater coordination across programmes. There are some
interventions that should almost always be tackled on a system-wide rather than
programme specific basis. Not uncommonly, a package of interventions is needed.
One way of looking at what the Fund is doing on HSS is to look at its expenditures.
Within the Global Fund's seven budget categories, four (human resources; training;
infrastructure and equipment; and planning and administration) are considered to
contain 'a significant component of HSS expenditure'. For further information see
background note 4 'The Global Fund and health system strengthening: a short history '.
It is useful to examine the nature of funded activities more closely. One crude but
informative way is to review activities across approved proposals. The charts below
28
come from a review of 98 approved proposals in 21 countries. The way information is
presented varies across proposals, is often limited and not always very concrete, so this is
a purely descriptive analysis. Even so, the exercise gives some useful information.
Broadly, Box 4 shows that the main activity groups reflect the major constraints. The
pattern in box 4 was similar when analysed by disease component, except that laboratory
strengthening activities were almost twice as common in TB proposals than in the others.
Box 4:
Major categories of health system related activities, across
proposals
Number of proposals
0 20 40 60 80 100 120
Human resources & training
Monitoring & evaluation
Infrastructure, labs & equipment
Planning, organization & financing
Procurement & supply management
Source: Review of 98 approved proposals in 21 countries. WHO, 2006
Reviewing the nature of activities within these categories provides additional information.
Within the 'human resources and training' group, all but 2 proposals have training activities;
80% include the production of training materials, and activities concerning planning and
management are also common. Less than 50% have recruitment or remuneration related
activities. In terms of target groups for training, box 5 shows that over 80% of proposals
contain activities for clinical training of health care providers and community health workers.
14% of proposals contain training in procurement and supply management.
Box 5:
Training activities: target groups and focus of training, across
proposals
Number of proposals
0 20 40 60 80 100 120
Clinical training for HCWs
Clinical training for CHWs
Training for planning/management
Training for labs
Training for M&E
Training for procurement
29
In summary, the types of activities are all essential actions designed to contribute to improved
health systems and services. What is often less clear in the proposals reviewed is
o the extent to which the mix of activities funded constitute or are part of a balanced
package of interventions, for example for health workforce development, that fit
with national policy and strategy within the country concerned
o the extent to which these activities are expected to contribute to sustained
improvements across services and outcomes
Another way of looking at the nature of HSS activities supported by the Global Fund is
through individual country examples. The box below gives six examples in which the Fund
has financed at least part of a country's response to an identified constraint.
Box 6: six country examples of HSS strengthening activities supported by the Global Fund
Country Definition of the problem Definition of the response,
proposal in the proposal wholly or partly funded by the Fund
Malawi Argued, with supporting data, that the Asked the Fund to fund a portion of its costed
round 5 HSS health workforce shortage was a key emergency HRH plan, designed to implement
constraint to improving HTM outputs and the Malawi essential health package (which
outcomes but was too severe to be resolved includes HIV/AIDS, TB and malaria). Plan
on a disease specific basis includes both short and long term measures
Rwanda Argued, with supporting data, that overall A package of measures that included the
round 5 HSS low utilization of health services was due to extension of ongoing community based health
financial barriers and poor quality, and these insurance to additional provinces; providing
were critical obstacles to the success of HTM electricity to health centres in 6 provinces; and a
programmes mix of pre and in-service financial and HRH
management training
Cambodia Argued that Cambodia's achievements for The response focused on activities to promote
Round 5 HSS HIV, TB and malaria have been at the cost of alignment of GF and other programmes with the
increased system fragmentation; noted Health Sector Strategic Plan; strengthen
Cambodia is seriously off track for maternal managers' planning, monitoring and evaluation
and child health MDG targets. Argued for mechanisms at all levels, and strengthen drug
integrating GF programmes with core MOH forecasting, procurement storage and
functions. Focused on 2 areas of distribution systems.
fragmentation: health sector planning;
procurement and distribution systems.
Kenya TB is rising mainly because of HIV, and TB Focus of response: renovation of 33% of public
round 6 TB case detection remains low. Proposal argued dispensaries; some recruitment; accelerated
that the most effective response, as stated in activities to strengthen district level planning and
the national sector strategy and the TB plan, management and HRH productivity. Aim is for
is by improving delivery of essential health all districts to have comprehensive health plans
services that include TB/HIV, at primary by the end of the 5 year grant. In the TB
health care facilities. Argued that gains will proposal, the MOH Planning and Health Sector
not be realised if management capacity Reform units are responsible for the Service
remains weak. Noted that a national HRH Delivery Areas on district planning and
plan is still in development, & that districts management. Recruited lab techs will be trained
have increased managerial responsibilities. in Kenya's essential lab oratory package.
Mozambique Argued, with supporting data, that Emphasized the integration of scaled up HIV
Round 6 constraints included inadequate services with existing out and in-patient services.
HIV/AIDS infrastructure; scarce human resources; One of the 5 objectives ('strengthen health
cumbersome HR management procedures; systems'), included investing in pre-service
weak laboratory and drug procurement and training of basic and mid-level health
distribution systems; referral constraints; professionals as part of a national HRH plan, and
coordination and management bottlenecks establishing 11 provincial HTM coordination
teams.
Ethiopia Early Fund grants for TB and malaria, and While not part of a specific proposal to the Fund,
round 4 HIV, had large budget allocations these difficulties accelerated implementation of
for drugs and commodities. Ethiopia's solutions to improve procurement and supply
national pharmaceutical supply service management procedures. Only a small amount of
(PASS) was overwhelmed and slow. As a GF funds were used - to hire additional PASS
result, Fund disbursements were delayed. staff to manage pharmaceuticals; vehicles,
The MOH argued this was an opportunity to computers & office equipment - but with a major
strengthen PASS, rather than bypass it - even effect. By mid 2005, drugs and commodities were
temporarily. arriving at lower levels of the health system more
reliably .
30
3. Clearer parameters for Global Fund support to overcome HSS constraints
As already stated, the Global Fund can influence health system development in two ways:
through direct funding and through indirect influences. Both need to be kept in mind.
Some parameters for Fund investment already exist. Activities must clearly contribute to
improving (and sustaining) HTM outcomes, in ways that strengthen health systems.
Activities that are catalytic in nature, for example that encourage bridging opportunities
across programmes where appropriate (such as HIV and reproductive health; blood safety)
are allowable. Major infrastructure is excluded. The Fund's commitment to responding to
country-defined investment could suggest that the Fund should not further 'cherry pick' areas
for HSS investment. However, the lack of more specific parameters, or boundaries, has
caused confusion: for countries in understanding what is 'allowable funding'; and for the TRP
in reviewing proposals. Concerns about Fund mandate creep, and the sense that spending on
health systems is a 'bottomless pit' have also repeatedly surfaced in Board meetings.
An increasing number of countries have credible national health sector strategies, Medium
Term Expenditure Frameworks; national health workforce development plans etc. The
costing of these and also disease programme specific plans is becoming more common place,
though it is by no means universal. In line with its commitment to the Paris harmonization
and alignment agenda, the Global Fund is already increasing its support for such 'programme
based' approaches (a term which includes both technical programmes and sector
programmes). Global Fund support to Mozambique and to Uganda are two examples of the
latter. Partners need to have confidence in the strategies and plans to which they are
committing support, and principles for validating such strategies and plans are currently
being developed5.
Where such strategies are not in place, the Global Fund can certainly encourage their
development. In addition to doing this, an acceptable and workable approach to clarifying
the scope of what the Fund can invest in and how, is needed. It needs to be as simple and
flexible as possible. The rest of this note sets out a few ideas on possible approaches, for
discussion at the consultation.
3.1 Parameters for 'allowable HSS activities' can be set in a number of different ways
As a set of 'thematic' or focus areas - for example, health workforce development;
procurement and supplies management; diagnostic services; information systems
Based on a particular level of the health system - for example, the primary focus of
funding could be on activities that have a service delivery, or district level, focus
By defining excluded or non-allowable activities more explicitly.
By having greater clarity of what types of HSS activities it makes sense to fund on a
programme specific basis, and what should be funded through other means - see Box 7.
5 These include proposals from various bilateral donors, and the 'Health as a Tracer Sector' workstream
for the Third High Level Forum on Aid Effectiveness to be held in Accra in September 2008
31
Spectrum of HSS actions that might be financed under GFATM
Not mutually exclusive
HSS via financing HSS via full or HSS via partial HSS via partial
for interventions partial seed financing for financing for
within HTM financing for scaling-up HSS sector-wide
projects and/or innovative HSS initiatives programmatic
programmes interventions HSS support
A few examples:
•Lab network strengthening •Public-private mix •Expansion of a CHW or •a medium-term health
support, especially for HTM models involving HTM health extension worker sector-wide programme
diagnostic processes and other essential program covering essential that is endorsed by
interventions (via private package of services Government &
•HRH development
providers, NGOs and/or •Expansion of rural health partners, and
strategies, including task
communities) district management incorporates essential
definition & shifting, within
strengthening programme health services and
HTM programs linked within •Testing new HRH
system strengthening
national HRH plans recruitment/retention • overall public health
approaches laboratory strengthening
Potentially great sustainable impact across health MDGs,

but more difficult to measure HTM impact
in 2-5 yr time frame? ?
More limited scope, but may be easier to
measure impact on HTM outputs/outcomes
3.2 'Parameters plus': parameters need to be combined with a few principles….

However the parameters for allowable funding are eventually articulated, some additional
features or good practice principles are needed for them to work as intended. The following
are set out for discussion. They would apply whether or not there is a separate HSS
component in Fund proposals.
1. Parameters should be considered as a guide not a rigid blue print. They must retain
some flexibility to respond to different country circumstances, provided a compelling
case is made in a proposal
2. Proposed interventions should be based on best available evidence. Such knowledge is
increasing but it could be made more readily accessible. Box 8 gives one example. It is a
draft framework, being developed by GHWA and WHO from an analysis in eight low
income countries, that could be used as an 'aide memoire' for developing or reviewing
proposals concerned with scale up of health workforce education and training.
Box 8 Draft framework for successful country scale-up of health workers education and training
o Political will, including sustained government involvement and support
o Government commitment to short and long-term workforce planning
o Collaboration between several partners including government actors; professional groups, providers and
donors
o Significant financial investment, including government and if necessary donor budgets
o Commitment to fill the gap with appropriately trained health care workers
o Focus on health outcomes in the choice of types of workers to be produced, and a multi-skilled team
o Significant expansion of pre-service training capacity for all types of workers, including management and
administration
o Strengthened health workforce management and leadership
o Health information systems producing reliable health and health workforce data
o A labour market with the capacity to absorb and retain new health workers, and ensure productivity
3. Proposals should build on wide experience of good strategy design

The effects of similar interventions can vary in different settings, and can be
unpredictable. However, in many instances there are some reasonably well-accepted
'good' design principles to enhance system-wide positive effects.
Box 9: Proposal design principles: some examples of do's and don'ts

DO
32
Build on existing primary level services, support systems, training approaches and materials to
the maximum extent possible. Where this is not possible in the short run, have a plan of how to
do so in the longer run
Ensure proposed activities constitute or are part of a balanced package of interventions, and fit
within a national strategy where it exists
Think through the implications of programme-specific activities for other national health
priorities and services - for example the effects of individual programme incentives
Set out the actions to be taken to mitigate any possible negative effects
DON'T
Develop separate financing systems for individual services or programmes
Demand data outside national plans; unreasonably frequent reporting
Forget to keep an open mind, and look out for unintended as well as intended effects
Forget to think of investments that reflect the Global Fund's comparative strength but would
benefit all programmes and services
4. A sense of costs is needed

There are many different ways of looking at costs, that serve different purposes. Global
price tags, for example for the health workforce crisis, or the overall resource envelope for
meeting the health MDGS, generate much needed attention to a problem but can also
generate alarm and resistance in Ministries of Finance. Some cost estimates are based on
what it would cost to entirely eliminate all constraints, while others focus on costing a
reduction of selected constraints. The costs of 'unblocking' some bottlenecks can be large,
but the costs of removing others can be rather small - for example, funds for fuel to carry
out supervisory visits. Pooling of resources may allow funds to go further. The well-
known TEHIP project in Tanzania estimates that its impressive gains in child survival
were achieved with an extra US$0.80 per person per year. It was the flexibility given to
district teams in the use of their additional funds, which they spent on a package of often
unspectacular but effective actions, that was more important. The costs of certain types of
'catalytic activities' may also be fairly small - e.g. seed funding to develop a workforce
strategy - but may help release a much larger tranche of funding from elsewhere.
Realistic cost estimates - maybe for several different 'scale-up' scenarios - provide a basis
for debate and agreement with key stakeholders. Subsequent financing can then be
mobilised from multiple sources. One of the factors behind Malawi's success with its
Emergency Human Resource Programme , which was costed at US$272 million, was that
it was based on what was thought to be an ambitious but attainable goal of raising
Malawi's staffing to Tanzanian levels over six years. It was subsequently funded by the
Government of Malawi, DFID and the Global Fund.
5. Confidence that returns from investment are possible, within a reasonable timeframe.
Some HSS activities take time to deliver results, but others can generate returns relatively
quickly. Two examples are given here. Malawi's six year Emergency Human Resources
Programme began in April 2005. It has a five pronged approach that includes salary top-
ups. It aims for short term improvements while pursuing longer term goals. Nine months
later a positive impact could already be seen: 430 more employees were receiving salary
top-ups. Health managers thought the top-ups were the main factor in stemming the flow
of staff, especially nurses, from the public sector. In Tanzania, there have been rapid
national gains in child survival between 1999 and 2004. Preliminary assessment suggests
that a series of health systems events have contributed to improved coverage of essential
interventions: SWAp and basket funds; increased public spending; improved planning
and management; an increased drugs budget; innovative approaches to expanding bed
net distribution and malaria treatment. There is optimism that the trend will continue.
6. Credible metrics exist for tracking changes in health systems performance

Tracking progress is a key element of good practice, for two reasons: for good
management - allowing timely 'course corrections' to be made if needed; and for
accountability. A health system monitoring system needs to capture trends in health
system inputs and outputs, supported by coverage data with a small set of indicators.
Progress can be summarized with a country health system metrics dashboard that
33
includes key indicators for these core areas and describes progress on an annual or bi-
annual basis. An international meeting organized by the Health Metrics Network and
WHO in 2006 took stock of the status of indicators and measurement methods and
developed guidance for the potential contents of a dashboard6. Around 50 countries are
engaged with HMN, and are also in the process of assessing their information systems
and developing their individual Health Information System development 'road maps'.
7. The process of proposal development, not just its technical content, is critical to achieving
effective implementation. The short GAVI note provides lessons from its recent
experience with the GAVI HSS window.
8. Lastly, mutually acceptable ways (to countries and to GHIs) to channel funds is needed
Session 6 will focus on this.
In summary
This note is designed as a starting point for discussion at the consultation. There are
consistent messages about the biggest health system constraints to improving HIV/AIDS, TB
and malaria outcomes. In determining any response, it is important to remember that a health
system, like any other system, is a set of inter-connected parts. Changes in one part will have
repercussions elsewhere, which may be positive or negative. Second, in whatever way the
parameters are finally framed, there will be practical implications to consider: for the Fund,
for countries and for partners. Box 10 sets out a framework for considering these implications.
Box 10
Implications for
partners
Country analyses Better guidance and

own constraints – support for constraints
using existing analyses analysis if needed
if possible
Country defines Better access to current
actions needed – international evidence;
Global Fund sets based on
costing tools etc
broad HSS parameters Proposals best evidence;
based on commonest Funding national strategies
HTM constraints local circumstances;
other resources Health system metrics
Country for tracking progress
implementation; operational
monitoring;
course corrections
as needed
Implications for
Global Fund
Proposal form design Implications for countries
TRP membership Country proposal processes
include appropriate spectrum of stakeholders
TRP review procedures
6 http://www.who.int/healthinfo/health_system_metrics_glion_report.pdf
34
Annex 5
Background note 4, July 30 - 31 2007 Consultation
The Global Fund and health system strengthening: a short history
This paper summarizes the Global Fund to Fight AIDS, Tuberculosis and Malaria's (Global
Fund) experience in funding health system strengthening (HSS) activities. It is based on
previous Global Fund documents, and incorporates more recent experience.
I. Global Fund mandate

The Global Fund's founding principles, as set out in the Framework Document, state that the
Fund will:
• Support the substantial scaling up and increased coverage of proven and effective
interventions, which strengthen systems for working: within the health sector; across
government departments and with communities; and
• Support programmes that address the three diseases in ways that will contribute to
strengthening health systems.
• Support performance based funding, and a focus on results
The key issue is therefore not whether the Global Fund should invest in strengthening of
health systems, but rather how it can best do so.
II. Global Fund expenditures on health system strengthening

Out of the Global Fund's seven budget categories, four categories may contain significant
components of HSS expenditure: human resources; training; infrastructure and equipment;
and planning and administration (shown here in blue and green). Trends by budget category
over 5 proposal rounds are shown in box 1.
Box 1: Trends in Global Fund expenditures
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Round 2 Round 3 Round 4 Round 5 Round 6
Human Resources Infrastructure & Equipment Drugs Other
Training Planning & Administration Commodities and Products
35
III. Global Fund application processes for health systems strengthening
Over the seven rounds there have been a number of variations in how to apply for funds for
HSS activities.
In Rounds 1-3, applicants had the option of applying for HSS expenditures through a
'cross-cutting' (or "Integrated") component in addition to the three stand alone disease-
components (plus HIV/TB component). Applicants were able to request funds through
this integrated component for programmes addressing system-wide or 'cross-cutting'
issues relevant to the fight against the three diseases. Rounds 2 and 3 guidelines stated
that 'where relevant', intervention strategies for the three diseases should be integrated to
maximise available resources.
• Round 4 continued the specific "Integrated" component but with increased information to
applicants on what could be requested. Guidelines defined this as “a comprehensive
response to the three diseases that focuses on system-wide approaches and cross-cutting
aspects to strengthen health systems”.
• Round 5 introduced a separate "Health Systems Strengthening" component, to improve

upon and clarify the “Integrated” component in Round 4. In practice, the guideline
definitions for both were very similar.
• In Round 6, there was no separate component for HSS. Applications for activities to
strengthen health systems could only be included within the disease component for
which such activities were deemed necessary.
• Round 7 used the same approach as Round 6, but introduced the notion of a health
system 'strategic action' within a disease component. Round 7 guidance more explicitly
allows applicants to request funding for cross-cutting HSS actions that will benefit other
components, whether or not these are included in the application, provided that there is
no duplication of funding requested.
IV. Global Fund guidance on allowable activities: scope and trends

There has been a significant evolution in the Global Fund’s guidance for applicants.
1. The readiness to provide grants to public, private and non governmental
programmes to address the three diseases in ways that contribute to health systems
strengthening, and the need to consider how to sustain results, has been explicit in all
rounds.
2. In terms of directly funded HSS activities, the implicit scope of allowable activities has
remained largely the same over succeeding rounds, but examples of the types of
activities that the Global Fund is willing to fund have become more extensive and
explicit, in efforts to provide greater clarity. (See table below)
36
Round Examples of allowable HSS activities, given in guidelines
1 Guidelines state any proposed actions must be shown to be linked to achievement of
clear, measurable and sustainable HIVAIDS, TB and malaria outputs and outcomes.
One explicit example given: strengthening of comprehensive commodity
management systems at country level.
2 Four examples listed: actions that enhance increased access to health services;
recruitment and training of personnel and community health workers;
strengthening of comprehensive national commodity management systems;
strengthening of information systems
3 Same as above, but expanded the examples of allowable health workforce activities
to include interventions to improve deployment and supervision
4 Four areas mentioned: human capacity development (including training and
compensation for both technical and managerial staff, in public and private sectors);
procurement and supply management systems; monitoring and evaluation systems;
coordination
5 Same four areas, plus operational research (check wording)
6 11 examples; with proviso that these include but are not limited to: HRH
mobilization, training and management capacity development; general local and
high level management capacity development; infrastructure renovation; equipment
maintenance capacity; health information systems; supply chain management;
innovative financing mechanisms; engagement of community and non state
providers; quality of care management; operations research
7 15 examples of HSS strategic actions: governance; strategic planning & policy
development; monitoring and evaluation; coordination / partnerships; community
and client involvement; policy research; information systems; health management;
health financing; human resources; essential medicines and other pharmaceutical
products management; procurement systems; logistics including transport and
communications; infrastructure (excluding large scale investments); technology
management and maintenance.
3. While proposals have always been required to base their plans on an analysis of
technical programme need, from Round 5 guidelines have explicitly required any
proposals to be based on a comprehensive review of 'health system capacity' (both
public and private). In Round 7 the wording is for proposals to be based on an
analysis of health system constraints.
4. Round 7 emphasized for the first time a request for applicants to demonstrate that
they had thought through the implications of proposed activities on other health
services, and had plans for risk mitigation where needed.
5. Over succeeding rounds there has been an increasing emphasis on alignment with
national policies and processes, with more explicit requirements for proposals to
situate proposed activities within the broader national context; to explain how they
complement and align with national health sector strategies and broader
development frameworks; and to demonstrate synergies and linkages with existing
grants and to other related donor-funded programmes. Round 6 and 7 proposal
forms contained a section for those wanting to use common funding arrangements as
the channel for receipt of Global Fund additional financing.
37
V. Lessons from experience, with a focus on Rounds 5 and 6
Rounds 1 to 4 'integrated' proposals had low application and low success rates: only one
proposal was approved out of a total of ten submitted.
In Round 5, out of 30 applications for the 'HSS' component, only three were approved (10%).
Observations from the TRP

The TRP observed that the successful HSS proposals, which covered different dimensions of
health systems, shared characteristics of other successful proposals: they were generally
focussed on a small range of activities; were judged to be realistic; had clear objectives,
strategies and activities which were linked to coherent budgets and work plans. They made a
compelling case for the HSS activities, and argued this would contribute to the fight against
one or more of the diseases. Unsuccessful proposals tended to be too broad and ambitious,
too vague in their objectives, proposed activities, and with poor work plans and/or budgets.
Nevertheless a greater proportion of HSS than disease specific proposals were judged below
standard. While some have argued that this was the first time, and - as happened with
disease components - the quality could be expected to improve in subsequent rounds, there
were TRP observations specific to the HSS component that suggested this would not be
automatic.
• The definitions of what constitutes an HSS proposal were too vague and too broad with
little guidance to applicants on any specific focus.
• The proposal form was originally designed for the disease specific components and was
largely unsuitable for the submission of HSS proposals.
• Insufficient guidance was provided on what an effective linkage between HSS and a
disease component should or could look like. In many proposals, these linkages were
superficial and not convincing.
• There was insufficient clarity on whether to include HSS elements only in the HSS
proposal or in both HSS and disease-specific proposals. This had the obvious downside of
potential duplication between two successful applications, or in few cases, a disease
component was recommended for funding but was contingent for successful
implementation on resources applied for in an unsuccessful HSS component.
• The Global Fund system is not currently set up to generate strong HSS proposals nor to
evaluate these effectively.
•
In Round 6, in which HSS elements were reintegrated into the disease specific components
on recommendation of the TRP, the TRP had the following observations on HSS:
The overall quality of the HSS elements proposed within the many of the Round 6
proposals remained low.
There remained a lack of justification for proposed HSS activities on the basis of specific
constraints faced by countries.
As in the previous round, proposals were too broad, ambitious and vague in their
objectives and/or proposed activities, work plans and budgets.
The failure of many proposals to locate specific proposed HSS strategies within the
broader national context made it difficult for the TRP to assess their likely impact on
disease-specific targets and on the broader healthcare system.
Some proposals suggested HSS activities that were very likely to undermine other
elements of the healthcare system.
The TRP made the following recommendations
38
• The Global Fund needs to define the scope, boundaries and extent of activities that it is
willing to fund under the rubric of HSS activities. The broad scope in Round 6 created
difficulties for countries in focussing their proposals and caused significant problems for
the TRP in evaluating such proposals.
• Any process to clarify the scope of HSS activities would need to ensure harmonization
and consistency between the Global Fund’s HSS mandate and those of other technical
partners and agencies.
• Activities that fall within the scope of Global Fund mandated activities must be located
within national policies, plans and standards, and justified in terms of disease specific
targets. [It suggested criteria for HR activities, equipment and infrastructure].
• There is a need for more specific guidance to applicants to provide a clear explanation of
HSS related constraints, and how proposed activities will address them; and on the
nature of linkages between HSS elements and the disease proposal.
• There is a need for the Global Fund to work with its partners to develop an agreed
harmonized toolkit of monitoring indicators to track the results of investments in HSS
elements and for applicants to be guided to include these within their proposals in future
funding Rounds.
The TRP also suggested that, as part of the Secretariat's agenda of working to strengthen
CCMs, it consider CCM capacity to develop/oversee proposals with stronger HSS elements.
Conclusion
The Global Fund Board, its Committees, the TRP, the Secretariat, country applicants and
supporting advisers have all wrestled with how to define, interpret or apply the guidance on
the ways in which the Fund can support the strengthening of health systems. The debate has
been influenced by a wealth of studies and by developments in other agencies, many of
whom who have been re-examining their role in the international health system agenda.
Another significant development has been the Global Fund's commitment to the Paris
Principles of Harmonization and Alignment. If taken to their logical conclusion, these will
also have a major influence on how the Global Fund supports health system strengthening.
39
40
Annex 6
Background note 5 for July 30 - 31 2007 Consultation
Experiences of the GAVI Alliance Health System Strengthening

Investment
1. WHAT IS THIS?
This background paper shares the experiences of the GAVI Alliance Health Systems
Strengthening (HSS) investment in terms of history, principles, processes, analysis of
proposals and lessons learnt. It has been drafted by the GAVI Secretariat in preparation for
the consultation on the Global Fund's Strategic Approach to Health System Strengthening 30-
31 July 2007 and forms the basis for a presentation that will be made at the meeting.
Reference documents made available include:

a) GAVI Alliance 2007 HSS guidelines and application form7
b) Original GAVI HSS investment case approved by the board in December 2005
c) GAVI HSS board updates January 2006 and May 2007
d) GAVI HSS task team Terms of Reference 2007
2. JUSTIFICATION FOR A SEPARATE GAVI HSS FUND AND BOARD APPROVAL

It must first be emphasised that the GAVI and GFATM business models are different. It may
therefore not be possible to draw comparisons for what is ‘right’ for GAVI and what is ‘right’
for GFATM. However equitable, efficient and effective delivery of any ‘health package’ such
as basic, new or under-utilised vaccines cannot be in isolation and needs to be seen in the
context of an integrated, strong health system. Health system barriers / bottlenecks need to
be identified and addressed if there are to be sustainable increases in vaccination coverage.
These barriers / bottlenecks are often the same as those for delivering other child health
packages and therefore overcoming them is crucial for achieving MDG 4.
In 2004, the GAVI Secretariat commissioned a study to review the key barriers to increasing
immunisation coverage. This study revealed that the barriers were broader than the
immunisation system alone and included health workforce allocation and motivation,
transport, fund flow to peripheral levels and planning and management at peripheral levels.
Also acknowledging that GAVI’s investment in new vaccines needs to be balanced with
investment in strengthening delivery mechanisms, this study helped stimulate the drafting of
an investment case for a separate funding window on health systems strengthening (HSS).
An initial reference group8 was constituted which helped design the HSS investment case
throughout 2005 and this was presented to (and approved by) the GAVI boards in December
2005. Although the initial approval for a separate HSS investment was $500 million for 2006 -
2010, the time horizon is for 2015, pending results of an evaluation in 2010.
Risks acknowledged: Many board members recognise the need for this investment and
acknowledge that it is more ‘risky’ than other GAVI portfolio investments. Measuring
attribution may not be possible, robust monitoring and evaluating processes need to be
designed, best practices need to be documented, countries need to drive processes forward
and steps need to be put in place to increase financial accountability and transparency.
3. ELIGIBILITY, BUDGET AND GUIDING PRINCIPLES
7 http://www.gavialliance.org/Support_to_Country/Forms/index.php
8 Membership included developing countries, WHO World Bank, Unicef, USAID, Vill and Melinda Gates
Foundation, DANIDA, civil society, Norad, CIDA, DFID, PATH, Aventis, HLSP consulting and the GAVI Alliance
secretariat
41
Eligibility criteria: All 72 phase-two GAVI eligible countries are eligible for HSS funding.
Only national Governments may apply, although some exceptions may be considered for
fragile states. Countries should have completed a costed immunization comprehensive Multi
Year Plan on immunization (or its equivalent) for the duration of the HSS proposal. GAVI
HSS funds should not be used to purchase vaccines and should be in addition to (not
displace) existing budget lines.
GAVI HSS budget ‘envelopes’ for countries: The duration of the GAVI HSS proposal should
be aligned with the duration of the country’s health sector plan (or its equivalent). The
country’s potential budget envelope is calculated as follows:
• Countries with a GNI per capita <$365 per year - eligible for $5 per newborn per year.
• Countries with a GNI per capita >$365 per year - eligible for $2.50 per newborn per
year.
What can a country apply for? As long as a country meets the eligibility criteria (above),
GAVI HSS funding should target the “bottlenecks” or ‘barriers’ in the health system that
impede progress in improving the provision of and demand for immunisation and other
child and maternal health services. The impact should be at peripheral and service delivery
level. Although three non-exclusive themes are suggested (health work force, organisation
and management at district level and below and supply, distribution and maintenance
systems) HSS funds may be considered to fund other activities that have been identified as a
priority by the national government to overcome health system barriers to increasing
immunisation coverage.
Guiding principles: 10 guiding principles are outlined on pages 4 and 5 of the HSS
guidelines. Four are important to highlight:
i) Country driven approach: The countries needs and direction should guide the direction
of the HSS design and it is up to the Secretariat and Alliance partners to respond to these
needs. This obviously also increases country ownership.
ii) Alignment: Any GAVI HSS investment should be aligned with the objectives, strategies
and planning cycles of existing Government health sector policies and frameworks
iii) Inclusive and collaborative: All key stakeholders in health system strengthening
(beyond the immunisation programme) should be involved in GAVI HSS. Government
entities, partners, civil society, and the private sector should all be informed and
involved, as appropriate, in the planning, implementation and evaluation stages.
iv) Performance based: The linkage to EPI and EPI coverage as the main outcome ensures
that the proposals are performance oriented. This should be maintained within the
larger health systems initiative.
4. GAVI HSS COORDINATION MECHANISMS
Three main coordination challenges include: i) ensuring that global level and country level
coordination mechanisms provide added value to the implementation of the HSS window; ii)
strengthening linkages between immunisation programmes and health systems
strengthening and iii) strengthening linkages and sharing experiences with other initiatives
involved with health systems strengthening.
GAVI Alliance HSS task team: Implementation of the GAVI Alliance HSS investment
receives guidance and recommendations from a global level GAVI HSS task team. This 10
member task team is co-chaired by the 3 multilaterals (WHO, UNICEF and World Bank) and
has representation from DFID, NORAD, USAID, developing countries, civil society, Bill and
Melinda Gates Foundation and the GAVI Alliance Secretariat. Despite each institution having
different paradigms for health systems strengthening and the difficulties in reaching
consensus in such a diverse group of partners, the task team has drafted communal work
plans and designed and greatly assisted the implementation of the GAVI HSS opportunity.
Through its co-chairing mechanism, this entity has also helped strengthen the coordination,
cooperation and information flow between the three multilaterals on health systems
strengthening issues.
42
Country coordination mechanisms: Use of existing national health sector coordination
mechanisms at country level9 for the drafting, implementation and monitoring of the GAVI
HSS proposal. The proposal should be within the context of other ongoing health sector
activities and planning processes. The GAVI HSS proposal development process has helped
bring partners involved with HSS together.
Strengthening linkages between EPI and health systems strengthening: Although there
have been some issues of fund control and proposal writing in some countries, in general the
emphasis has been on encouraging planning departments to take the lead with technical
inputs from EPI departments. This has helped increase mutual understanding and often
empowered departments of planning.
Strengthening linkages with other initiatives: In the spirit of the Paris Declaration, other
initiatives10 involved with health systems strengthening have been included in information
sharing and invited to various GAVI HSS meetings to provide inputs. Three joint country
visits have been undertaken with GFATM and two of these visits also included HMN.
5. PROPOSAL DEVELOPMENT, GUIDELINES SUBMISSION, REVIEW AND FUND

FLOW PROCESSES
Proposal development grant: Countries have access to a grant of up to $50,000 which is

meant to assist countries with stakeholder consultations, and drafting a proposal that aims to
overcome some of the health systems barriers. Many countries have not accessed this funding
yet, but used other sources in the meantime and also used existing health system and EPI
reviews. Although these grants were meant to stimulate the support of in-country and
regional support for technical assistance, 43 of 49 countries applying for this grant have asked
for funds to be channelled through WHO and used international consultants to help draft
their proposals.
Guidelines: The 2006 HSS guidelines and application form received much feedback from
partners and countries and these were revised for 2007 on the basis of this feedback. The
guidelines highlight the principles and practice of GAVI HSS.
Review process: When a proposal has been drafted in-country it is expected that an in-
country review takes place that helps not only make the proposal more technically robust, but
also ensures stakeholder ‘buy in’ to the process. In the future there might be an opportunity
for regional peer review, where countries are able to review each others proposals and make
comments before submission to the GAVI Secretariat. Once a proposal has been submitted to
the GAVI Secretariat it is ‘pre-reviewed’ by WHO to ensure consistency, completion and cross
checking of figures and documentation. Proposals are then reviewed by an Independent
Review Committee (IRC) of 10 people (9 reviewers and 1 chair) who make recommendations
to the Board for approval or not. There have been 3 rounds of HSS proposals since last
November and their financial overview is in annex 1.
Approval and fund flow: Once a proposal has been recommended for approval to the board
and if the board approves it, funds are expected to flow to the country within 8-12 weeks.
Much of the HSS funding will come from the International Financing Facility for
Immunization (IFFIm) and this mechanism requires a separate board meeting in itself.
6. 31 GAVI HSS PROPOSALS RECEIVED SO FAR
Of the 31 new country proposals submitted to the GAVI Secretariat, 16 have been approved
for funding (details in annex 1) and these approved proposals are available on the GAVI
Alliance website. An in-depth analysis of bottlenecks identified and activities supported by
9 Such as the Health Sector Coordination Committee

10 GFATM, HMN, Global Health Workforce Alliance, Stop TB and others
43
GAVI HSS funding will be undertaken and made available for the board meeting in
November and after each round in 2008. Most health system bottlenecks are related to human
resource shortages or training, infrastructure weaknesses, transport or management and
coordination at peripheral levels.
7. LESSONS LEARNED
Need for quality technical support: All countries identify the need for quality technical
support (to assist in developing and implementing proposals) that is delivered in a locally
appropriate way. However, scaling up any institutional capacity to respond to this need
without the usual reliance on international consultants remains challenging. The long term
GAVI HSS support provides an opportunity to support national and regional institutes to
provide technical assistance in a more sustainable and locally appropriate manner.
Country driven and learning approaches: Each country is different and has its own
bottlenecks to deliver services. There is no ‘one size fits all’ and putting the countries ‘centre
stage’ has helped drive processes forward to strengthen partner support. By documenting
lessons learnt and identifying best practices, the GAVI HSS opportunity remains flexible and
changes according to ‘what works’ and what does not. It should be noted that the business
model used by the GAVI Alliance is very different to that of the GFATM.
Coordination structures: The GAVI HSS coordination structures at global and country levels
have been extremely important in pulling partners together and ensuring information flow.
Paris Principles: The GAVI HSS is attempting to ‘operationlise’ the Paris Principles. The
lessons learned are all useful feedback for other initiatives that may try and operationalise the
same principles. However, some have expressed the concern that some countries may view
proposals that have been approved as a ‘blue print’ for successful funding and ‘cut and paste’
inappropriate strategies into their own country proposals.
Review of proposals: There is no ‘perfect’ way of reviewing complex proposals. The GAVI
HSS IRC has had to strike a balance between an academic / technically robust method and
pragmatic need to investment in health systems with proposals that can be implemented in
the world’s poorest countries. The IRC method of review has had to be adaptive and
responsive to needs.
8. CHALLENGES
Different paradigms of HSS: Consensus on HSS may not be possible amongst Alliance
partners and the Secretariat, but by putting the countries needs centre stage and continuously
learning and reviewing country needs and identifying best practices, this ensures that
partners respond to a process that is being driven by countries.
Need for clear concise guidelines and application guidelines: The proposal drafting and
review processes are directly linked to the clarity of the guidelines and ease of filling in the
application forms.
Monitoring and evaluation: As the GAVI HSS support is such a country driven approach,
each country’s proposal and therefore indicators are different. Some countries may use a
basket funding approach which makes it difficult to measure any attribution of the GAVI HSS
funding. Measuring impact and ensuring the evaluation planned in 2009-2010 will help guide
the boards on further potential investment. This will be a key piece of work. The monitoring
IRC will countries annual progress reports and decide whether countries have reached their
stated objectives. As impact indicators may not be reached for several years, it may be
difficult to measure the actual implementation for several years and perhaps the first few
years may be viewed as an ‘investment’.
44
Operational Research: Despite operational research being promoted within country
applications, very few countries have taken advantage of this opportunity. It is therefore
suggested that global level initiatives and literature reviews help provide evidence based
materials to guide country policy and decision makers
Accountability and risk mitigation: Steps are being taken to put in place mechanisms that
will reduce the chances of mismanagement of funds.
Relatively small budget compared to the need of the sector: Despite great expectations of
the flexible GAVI investment, the budget is small in comparison to the needs.
45
ANNEX 1 Financial overview of GAVI HSS approvals over 3 rounds
HSS Approvals for 3 Rounds
Country 2007 2008 2009 2010 2011 Total
Round 1 $92,112,500
Burundi $2,704,000 $2,274,000 $1,754,000 $760,000 $760,000 $8,252,000
Cambodia $1,850,000 $1,850,000
Ethiopia $55,839,500 $12,629,500 $8,025,500 $76,494,500
Korea DPR $450,500 $1,308,000 $1,027,000 $1,026,000 $549,500 $4,361,000
Kyrgyz Rep $424,000 $255,500 $255,500 $220,000 $1,155,000
Round 2 $77,625,000
Congo DR $21,526,000 $15,717,500 $11,910,000 $7,661,000 $56,814,500
Georgia $69,000 $122,500 $122,500 $121,500 $435,500
Liberia $1,022,500 $1,022,500 $1,022,500 $1,022,500 $4,090,000
Vietnam $3,648,000 $4,705,000 $4,439,000 $3,493,000 $16,285,000
Round 3 $95,919,500
Afghanistan $6,700,000 $8,950,000 $7,200,000 $6,600,000 $4,650,000 $34,100,000
Cameroun $1,858,000 $1,912,000 $1,967,500 $2,024,500 $2,084,000 $9,846,000
Kenya $3,741,500 $2,964,000 $3,197,500 $9,903,000
Pakistan $16,898,500 $6,626,500 $23,525,000
$5,605,000
Rwanda $2,174,000 $1,715,500 $1,715,500
$6,335,000
Yemen $376,000 $2,198,000 $2,188,000 $1,573,000
Zambia $2,344,500 $573,000 $2,396,500 $1,291,500 $6,605,500
Grand Total $104,727,500 $73,245,500 $53,847,500 $25,793,000 $8,043,500 $265,657,000
Proposal Summary Submitted Approved Conditional Resubmission Conditionals approved

31 12 8 11 4
46

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The Global Fund Strategic Approach

to Health Systems Strengthening

Report from WHO to The Global Fund Secretariat

All rights reserved.

1 July 30 - 31 Consultation Agenda…………………………………………………..15

2 July 30 - 31 Consultation Participants…………………………………………….19

3 List of consultation core background materials;

4 Consultation background paper 3: Major health system constraints

5 Consultation background paper 4: The Global Fund and health

6 Consultation background paper 5: Experiences of the GAVI Alliance

Report from WHO to The Global Fund Secretariat

Box 1: The six building blocks of a health system

 Addressing primarily health systems policy and capacity issues

 Robust monitoring and evaluation frameworks

 better communication: of available evidence; of Global Fund policies and

3 Parameters for 'allowable HSS activities'

Purpose and options

 Activities must clearly contribute to "help health systems overcome constraints

Additional parameters can be set in different ways. For example,

Experience with different options, their pros and cons

Hum an r e s our ce s : br e ak dow n of activitie s

N um ber o f ac tiv it ies

T raining m aterials &

Source: Review of 98 approved proposals by WHO, 2006

A strength of the Global Fund's business model is that it is prepared to fund

An alternative to defining parameters more tightly is to provide examples of

Main messages from the WHO consultation process

 However, some greater clarity on exclusions might be useful.

 There are implications for partners of a broad parameters approach:

Purpose and options

Experience with different options, their pros and cons

Box 4 Can conditions support effective health system strengthening?

Yes, if the proposal development process leads to

 Any conditions should be simple, clearly communicated and have transaction

 The Global Fund is a partnership. Mutual accountability is important.

Box 5: Acceptable pre-conditions

o Proposals should be based on a sound analysis of HSS constraints to improved ATM

o Proposals should provide evidence of involvement of relevant stakeholders beyond a

5 The possible use and nature of ceilings for HSS funding

Purpose and options

Experience with ceilings, and their pro's and cons

 The use of an 'HSS floor', possibly as a percentage of any grant, might be

6 Pulling it together: modalities for supporting HSS

Options and experience

 Whatever modality of support is decided upon by the Board, good indicators

7 Summary and implications for different stakeholders

 The question of an HSS window is a procedural not a policy question. Opinion

 Consideration should be given to the possible implications of any decisions for

 Irrespective of the Board's decision on any of the specific questions, fostering

1. Better access to information

Technical agencies need to help improve access to evidence. Knowledge is increasing

2. Better technical assistance for health system strengthening

3. More coordination and co-operation at country level

5. Greater mutual accountability

6. Credible indicators for tracking health system performance.

Global Fund Strategic Approach to Health Systems Strengthening

0800 - 0900 Registration

0900 - 0930 Session 1

Addressing primarily health systems policy and capacity issues

Robust monitoring and evaluation frameworks

better communication: of available evidence; of Global Fund policies and

Activities must clearly contribute to "help health systems overcome constraints

However, some greater clarity on exclusions might be useful.

There are implications for partners of a broad parameters approach:

Any conditions should be simple, clearly communicated and have transaction

The Global Fund is a partnership. Mutual accountability is important.

The use of an 'HSS floor', possibly as a percentage of any grant, might be

Whatever modality of support is decided upon by the Board, good indicators

The question of an HSS window is a procedural not a policy question. Opinion

Consideration should be given to the possible implications of any decisions for

Irrespective of the Board's decision on any of the specific questions, fostering