Better Concept Notes, More Effective Funding
The Technical Review Panel, which analyses the technical merit of all funding applications to the Global Fund, reviewed 23 concept notes in July. It was the second window of concept notes to come up for review this year under the new funding model, after 10 applications were assessed in June.
The panel, known as the TRP, has also taken the opportunity to provide some more feedback to applicants on how to build the strongest possible case for funding. Bringing together experts in the three diseases and in broader development issues, the TRP found overall that concept notes are improving in quality, noting that some were especially robust.
Following a number of recommendations made in July after the first review window, the TRP has now made some further suggestions, five of them general and six technical, identifying areas where concept notes could be strengthened. Here is a summary of the latest recommendations:
One: Focus on Key Populations
The TRP concluded that many applicants could do more to address key populations, seen as essential to achieving the best possible impact at a time when resources are scarce. The panel also urged applicants to use epidemiological data to identify key populations, while drawing on best practice to guide the selection and design of interventions.
Addressing the rights of women and girls and those of young people who are at high risk of infection is important. The TRP also noted that interventions that support social and human rights have an important role to play alongside medical interventions.
Two: Sustainability Is Key
Applicants were encouraged by the TRP to make sure that programs are sustainable, no matter how much longer the Global Fund is expected to provide financial support to the country.
The panel sets much store by measures that help achieve this goal, such as integrating disease programs into the national health system; building capacity; and bolstering health data collection and monitoring and evaluation systems. The TRP also urged countries to support outreach to key populations through domestically funded programs, ideally giving a role to civil society organizations.
Three: Getting the Program Split Right
The TRP stressed that the breakdown of funding or “program split” between eligible diseases and health systems strengthening contained in the allocation letter is not intended to be prescriptive but is for information only.
CCMs should engage in a robust country dialogue with all interested parties before agreeing on a program split. The concept note should then give a clear rationale for the program split, regardless of whether the CCM has decided to adhere to the split contained in the allocation letter or to make significant changes.
Four: Improving the Quality of Concept Notes
The TRP said it was looking for more detail and consistency in budgeting and for evidence that health system strengthening is being adequately funded.
Five: Prioritizing for Greatest Impact
A clear presentation of priorities is strongly encouraged, showing how strategic choices can secure maximum impact of Global Fund investments against the three diseases and enhance health systems strengthening. Applicants are also urged to draw on geographical and demographic data and the experience they have gained from implementing previous programs in order to set clear priorities in their concept notes.
Countries that are eligible to apply for funding above the allocation amount should also make a clear distinction in their concept note between interventions that fall within the allocated amount and those that are outside its scope and therefore would require additional funding.
The TRP also made six technical recommendations:
One: WHO guidelines on antiretroviral therapy
Countries should strategically implement the WHO’s 2013 ART guidelines, which call for starting treatment at an earlier stage in the progress of the disease, with care. The move towards an earlier start to treatment should take into account overall treatment coverage and prevention activities. Recommendations in the WHO guidelines also need to be factored in, with a strategy to reach priority populations first. Applicants are encouraged to ensure their concept notes have a sufficient focus on prevention before moving to more ambitious treatment protocols. Without appropriate prevention efforts, ART will ultimately prove unaffordable and, therefore, unsustainable.
Two: Balancing investment in core DOTS and PMDT
Countries should prioritize case detection and the immediate treatment of all newly identified cases, maintaining and enhancing the performance of their basic TB program while building or expanding the capacity for programmatic management of drug resistant TB (PMDT). Barriers to accessing diagnostic and treatment services for general and key populations should be assessed, and countries should consider appropriate alternative service models to improve TB case detection and treatment support, drawing on lessons from pilot projects locally and globally. Countries should ensure the provision of a comprehensive package of services for PMDT that includes case detection, treatment and adherence.
Three: Joint TB and HIV concept notes
HIV, TB and TB/HIV interventions were given reasonable consideration in the joint concept notes, and the TRP had no serious concerns about the technical quality of the TB sections of the proposals. However, the TRP felt that TB and HIV experts may have failed to collaborate sufficiently in the preparation of joint concept notes. Some were significantly stronger for one of the two diseases. The TRP encourages joint concept note applicants to prepare an integrated concept note that reflects an appropriate balance of TB, HIV and TB/HIV activities, as indicated by the epidemiology of the country and known funding gaps.
Four: Working across Borders to Fight Malaria
Countries should make use of sub-national epidemiological data as a basis for prioritizing their interventions against malaria in resource-constrained environments. Countries should also collaborate with their neighbors to guard against a resurgence of malaria in border areas where progress is being made towards eliminating the disease.
Five: Health Systems Strengthening
The TRP said health systems strengthening is crucial to ensuring that programs are sustainable and in leveraging efforts by countries to fight the three diseases. In general, eligible applicants should therefore allocate money to HSS in their disease concept notes or in a separate concept note that specifically addresses health system strengthening.
Strategic investments in health systems can help maximize the impact of disease-related interventions and contribute to sustainability.
Six: Addressing Human Rights and Gender Issues
The TRP also urged applicants to include specific community, human rights and gender interventions in their concept notes that are adequately budgeted for and focus on key populations.
The TRP encouraged a stronger focus on interventions that work to change social norms rather than placing too much emphasis on purely medical interventions.