Global health initiative investments and health systems strengthening: a content analysis of global fund investments

In less than 20 years approximately 100 global health initiatives (GHIs) have been created to meet the Millennium Development Goals (MDGs). These GHIs, often established as public-private partnerships, have leveraged and mobilised unprecedented levels of funding channelled through governments and civil society organizations for specific diseases and targeted interventions [1, 2]. At country level this has led to a fragmentation of service delivery with unpredictable effects on health systems [3‐7]. Investment in health system strengthening (HSS) was proposed to mitigate adverse effects of the increasingly complex funding flows [3, 8‐13], address health system bottlenecks, and accelerate progress towards the MDGs [8, 10, 14‐17].

The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Global Alliance for Vaccines and Immunisation (GAVI), and the President’s Emergency Plan for AIDS Relief (PEPFAR), for example, channel funds for HSS based on the World Health Organization (WHO) health systems framework that identifies ‘six building blocks’ [7, 18‐21]: governance, financing, information, human resources, medicines and technology, and service delivery [21, 22]. This framework has been discussed extensively and many derivatives have been developed for describing and studying health systems [2, 7, 8, 18, 23‐30]. Because GHIs that support strengthening of recipient systems often use the WHO framework as the foundation of their HSS programs, the building blocks can be useful for cross-analysis of donor funding.

Our study, which aimed to quantify and categorize the Global Fund’s HSS funding, had two objectives: 1) to propose an adapted, operational framework with which to classify GHIs’ financial investments in HSS, and 2) to apply it to the Global Fund.

Although there is a body of literature on disease-specific investments by GHIs and their impact [8, 31‐35], there are relatively few publications on HSS-specific funding. Meanwhile, there has been substantial criticism that the Global Fund and other GHIs allocate insufficient resources to HSS [26, 36‐39]. This is likely a reflection of the debate within these global initiatives on the level of funding that should be allocated to HSS and whether the funding should be through disease-specific interventions or through more generic investments in health systems to benefit target diseases and beyond [18, 40]. The Global Fund allows investment in health systems both through disease-specific funding and through general health system strengthening activities [7, 41]. Over the years the Global Fund has used a range of approaches to fund HSS activities. For example, in 2006 there was a specific call for HSS grants in Round 5 [42], and ‘cross-cutting’ health system interventions could be funded in subsequent Rounds [42, 43]. Though the Global Fund provides an overview of their HSS financing [44], few studies have attempted to estimate the proportion of funding specifically allocated to health systems strengthening through disease-specific and/or to more generic (cross-cutting) interventions [17].

In 2010, the Global Fund provided approximately two thirds of international funding for fighting malaria and tuberculosis (TB) and nearly a quarter of funding for AIDS; claiming also to be the “largest multi-lateral channel for efforts to strengthen health systems” [45]. In 2011 the Global Fund provided 10% of total development assistance for health [13]. On 1 March 2008, the Global Fund launched Round 8. By 8 November 2008, 140 grants were approved for 65 low- and middle-income countries with a total value of approximately $2.5 billion for Phase I (almost twice as large as earlier Rounds). The largest single grant in Round 8 was awarded to Ethiopia for malaria with a value of approximately $133 million (5.4% of overall), and the smallest grant, worth approximately $532 000, was awarded to Tunisia for TB. Overall, Nigeria received the largest total amount of $340 million (~14% of the total for Round 8) through four grants – three dedicated to malaria and one dedicated to HSS.

When adapting the existing WHO health system framework [21], we considered other examples developed by Biesma et al. [8], Samb et al. [2], and Shakarishvili et al. [17]. The framework by Biesma et al. includes assessment of the Governance, Human Resources, and Financing building blocks, but not for activities in the Medicines and Technologies, the Service Delivery, or the Information subsystems - though monitoring and evaluation (M&E) is included [8]. The framework by Samb et al. is more comprehensive and is based on the WHO building blocks, but it was developed for assessing outcomes/effects rather than investment amounts [2]. The framework developed by Shakarishvili et al. was developed at the Global Fund specifically for tracking HSS investments using four domains of Stewardship and Governance, Health Services, Financing, and Monitoring and Evaluation (including health information systems) [17]. We built upon these frameworks to elaborate a classification mirroring the WHO six building blocks as many countries used the six building blocks framework when requesting funds from the Global Fund.

We systematically reviewed the grants funded by the Global Fund in Round 8 – the largest Round totalling approximately $2.5 billion for Phase I. We used a framework (See Table 1 for abridged version; Additional file 1: Table S1 for full version) that draws on the WHO six building blocks [21], frameworks developed by Biesma et al., Samb et al., and Shakarishvili et al., the WHO’s Framework for Action, Fixing Health Systems, and Systems Thinking by de Savigny and Adam, and discussions with experts in the respective fields [2, 8‐10, 16, 17, 21]. The adapted framework we propose provides a comprehensive (but not exhaustive) framing of system-level interventions requested by countries and funded by the Global Fund. Such a framework is meant to serve as a tool for cataloguing and mapping the HSS content and funding of any Global Fund proposal. Besides determining the monetary amount invested in each building block, analysis with this framework serves to determine whether or not health system strengthening is restricted to disease programmes or is more generic.

The first tier in the HSS Funding Assessment Framework is comprised of the WHO-defined health system building blocks. The second tier contains relevant functions of each building block, and at the third tier – the deepest level of resolution – describes system-level interventions (only the first two tiers are shown in Table 1). In the rare occasion that a budgeted activity (i.e. action having its own budget line in the detailed budgets provided to the Global Fund by the Principal Recipient) could not be classified at the intervention level, it was classified at the next highest level of resolution, either the second or first tier.

All grant materials were collated from the Global Fund internal database, with the consent of the Strategy, Performance, and Evaluation Cluster at the Global Fund. Overall 139 grants were funded in Round 8 including 52 grants dedicated to HIV/AIDS, 34 to tuberculosis, 46 to malaria, and 7 to HSS.

Of the 139 grants funded in Round 8, 27 were excluded from classification due to language (submitted in either French or Spanish) and budgets from 41 grants were unavailable at the time of analysis. We selected 52 grants from the remaining 71 grants; this sub-set is representative of the Round 8 grant portfolio in terms of region and disease-component (using chi-squared analysis; see Additional file 1: Tables S2, S3, and S4). The sub-set of grants is also representative of the Round 8 portfolio in terms of dollar-value. The median dollar (US$) value of grant agreements in Round 8 is US$8.5 million with an Interquartile Range (IQR) of US$22.9 - 4.4 million. The median dollar value of the study subset is US$9.8 million with an IQR of US$23.3 - 4.9 million.

Additional file 1: Table S1 of the Signed Grant Agreement, which outlines key activities, was analysed to establish the aims of each grant; the SGA’s main body of text was consulted for clarification when necessary. The Final Detailed Budget for Phase I, included in the grant agreement, provided to the Global Fund by the Principal Recipient, was reorganized to fit a standardised template in Microsoft Excel to remove any inconsistencies in formatting and, therefore, facilitate comparison. For every grant the grant number, region, agreed amount, and disease component, as well as the detailed description of each activity, Cost Category, and the Service Delivery Area (as assigned by the Principal Recipient) were included for accurate classification. Budget lines dedicated to activities for Phase II were excluded. Our calculations are based on the Sum Total found in the grant budget.

Upon standardization of the Final Detailed Budget in Microsoft Excel, three analysis-specific columns were added for classification using the HSS Funding Assessment Framework, tagging the activity as disease-specific or system-wide, and categorizing non-HSS activities. Each cell in the ‘HSS Classification’ column contained a drop-down menu with the HSS Funding Assessment Framework, and each cell in the ‘Disease-Specificity’ column contained a drop-down menu for differentiating between disease-specific and system-level classification. Each budget was then classified line-by-line with these two categories. If a budget line was deemed “Non-HSS”, it was tagged and classified using the drop-down menu containing “Grant Management”, “Salary / Per Diem”, “Commodities, Diagnostics, and Drugs”, or “Other”. A ‘Comments’ column was used for acronym definitions and notes or rationale about classification. For example, the activities supporting the development of a Malaria Surveillance Database in Swaziland were categorized as burden of disease data collection rather than design and development of HMIS. The corresponding ‘Comments’ column contained a note explaining why it was not classified as HMIS strengthening: “data is not routine nor is it gathered at the health facility level”.

In summary, each activity was examined using the process outlined in Figure 1.

An activity was considered “disease-specific” if it followed a conventional ‘vertical-programming’ approach - targeting system support within one or more building blocks specifically for AIDS, tuberculosis, and/or malaria. An activity was deemed “system-wide” if it explicitly targeted any building block, either individually or collectively, without explicitly targeting one of the three diseases [10].

Exclusion/Inclusion criteria were developed to distinguish between HSS and Non-HSS budgeted activities (see Additional file 1: Table S5). Stand-alone routine activities, such as salaries, meetings, rent, and ongoing operating costs, used to maintain rather than strengthen the health system were excluded. Although these are important activities fundamental to any health system, they do not improve or reinforce how the system functions nor do they alter the effectiveness or efficiency of the health system. If, however, they were nested within an HSS activity, then they were classified accordingly. For example, Swaziland’s budget-line “Technical assistance – Malaria Surveillance Database upgrade” that was nested within the activity “Development of Malaria Surveillance Database” was labelled as disease-specific HSS. Funding for training or support for persons working outside of the health system, i.e. anyone whose primary intent is anything other than improving or maintaining health (ex. social workers, police officers, etc.) was also excluded. The support of international technical assistance was also excluded because funding for temporary international consultants accrues not to local staff or the health system budget. Incentives for patients framed as patient support were excluded because the target is not the system but rather the patient.

Upon completing the classification of the 7,261 budgeted activities, the data were filtered and tabulated by region, building block, function, intervention, disease-specificity, and each aforementioned Non-HSS tag. The currencies were standardized to USD. Original grant agreements signed using the Euro (€) were converted to USD based on the start date of the grant agreement [46]. Start dates ranged from 1 July 2009 to 1 October 2010 (Additional file 1: Table S6 for dates and corresponding exchange rates).

Around 37% of the activities in our sample (approximately US$362 million) qualified as health system strengthening interventions according to the HSS Funding Assessment Framework. Of these HSS activities 38% (~US$139 million) were categorized as system-wide strengthening whereas 62% (~US$223 million) were considered to be disease-specific HSS activities (with an overall proportion of 14% (US$ 139 million) and 23% (US$ 223 million); respectively (Figure 2). Of the Non-HSS activities Commodities, Diagnostics, and Drugs received the most funding at 36% (~US$358 million) of the total.

Nearly one-third of the funds budgeted for HSS were dedicated to Service Delivery, whereas the Governance, Financing, and Information building blocks comprise under one-quarter of the funds (Figure 3).

Table 2 provides higher resolution to the division of resource allocation within each building block. The Governance, Financing, and Human Resources building blocks are heavily skewed towards a primary function, but the Information, Service Delivery, and Medicines and Technology building blocks have benefited from more even investments across multiple functions.

The HSS Funding Assessment Framework used for this study was developed to track, compare, and understand financial inputs for health systems by global health initiatives and applied to the Global Fund Round 8 [16, 38]. Activities were classified using signed Phase I budgets, not effective disbursements or expenditure. Most programs do not manage to absorb the entire budget, but budgets represent perceived priorities of the Principle Recipient. Each budgeted activity was classified along a building block rather than expected downstream outcomes; due to the non-linear interactions between building blocks one cannot attribute a given input to a given output. For example, Bulgaria’s “Training Roma community workers in outreach work and needs assessment of clients” was classified as ‘continuing education/on-the-job training’ and cannot directly credited to a given outcome such as access, equity, or quality.

Exclusion/Inclusion criteria were developed before the analysis during the reading of randomly selected Signed Grant Agreements and Original Proposals from Round 8 (see Additional file 1: Table S5). The inclusion criteria served more as a reminder for classifying a few frequently budgeted activities; the HSS Funding Assessment Framework (see Additional file 1: Table S1) is fairly comprehensive, and therefore obviated the need to establish extensive inclusion criteria.

One limitation to this first application study is the lack of a validity test for either the framework or the Exclusion/Inclusion criteria. Only one person reviewed the grants and classified activities. This retrospective analysis could be strengthened if there were two reviewers. The budgets are reviewed by the Global Fund before approval, so overall they are quite clear, but it could be useful if the reviewers were in contact with Principle Recipients to discuss and clarify specific budget lines if need be. Ideally, in order to avoid placing any further strain on Recipients and further fragmenting reporting systems such tracking/analyses could be incorporated into routine auditing. Guidelines could be developed for recipients and they could classify each activity themselves when designing the budget.

There are other inherent limitations to this study based on the Global Fund documents used. However our overall estimate of HSS support in Round 8 (37%) concurs with that of the GF’s own assessment (cited on website [44] on 24 January 2011 at the time of analysis).

The HSS Funding Assessment Framework could also potentially be applied to other GHIs supporting HSS activities, for example the GAVI Alliance and the PEPFAR, depending on the resolution of approved budgets. The GAVI Alliance uses HSS as a means to reach their immunization-specific objectives [1, 47]. This framework could capture the landscape of their investments as they utilize the WHO definition for health system and its four key functions [48]. It uses the WHO six building blocks, however, they are rephrased to fit into immunization program functions [38].

PEPFAR, is primarily interested in HSS activities as a means for ensuring a sustainable response to the HIV/AIDS pandemic. Its primary HSS activities include task shifting; and training, retaining, and creating support systems for health workers. Unfortunately, PEPFAR engages in bilateral partnerships that often circumvent the recipient health sector’s existing structures [49]. It is unclear what explicit HSS approach or framework PEPFAR uses; they avoid much of the HSS rhetoric in the literature they produce [50]. Thus, the use of such a framework could be particularly useful in elucidating specific PEPFAR HSS investments.

This study addresses concerns in the research and development community that the Global Fund does not sufficiently contribute resources to health systems strengthening. Our results show a substantial portion (approximately 37%; more than US$ 460 million) of the Global Fund Round 8 funds were devoted to HSS, and of this, 38% (approximately US$ 140 million) was dedicated to generic system-level interventions and 62 percent (approximately US$ 223 million) dedicated to system-level interventions for the target diseases. The Service Delivery, Medicines and Technology, and Human Resources building blocks received the most support with 31, 28, and 23% of the HSS funds (US$ 112 million, 101 million, and 82 million); respectively. Information, Governance, and Financing combined received 18% of the HSS funds (12, 5, and 1% (US$ 44 million, 19 million, and 4 million) ; respectively). Within each building block there was significant skewing towards only one or two major interventions.

Furthermore, this study highlights that the Global Fund finances a diverse set of HSS activities among recipients, even within a building block. The lack of activity-prescription by the Global Fund allows for more personalized and creative interventions. But the dramatic skewing among the building blocks suggests that the Global Fund needs to explicitly define what they are willing to fund within the Governance, Financing, and Information building blocks. Either the request for funds in these areas is rejected by the Global Fund, or awareness by the Recipients is lacking. Either way, the Global Fund, and potentially other GHIs providing HSS funding, needs to explicitly defined interventions that address these gaps while adhering to their mandate.

Of utmost importance as we move towards the deadline for the Millennium Development Goals, is the consensus of international donors upon the meaning of health system strengthening in the context of aid organizations. Although the discrepancies in approach and definition provoke continued reappraisal, crucial to scholarly and policy discussion, a clear definition will help better inform funding allocations by GHIs. The community needs also to decide how to harmonize efforts among agencies and with countries. There should be open communication between the recipient country and all donors to enhance the potential synergies between system-level interventions. Ideally these discussions will then also lead to an agreed-upon framework with which to evaluate HSS efforts across GHI boundaries.

There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. This and other retrospective studies are most useful when utilized for determining past efforts and future directions. It is necessary to understand the patterns of HSS spending within each recipient country when deciding how to proceed. Perhaps many have focused enough effort on their health sector infrastructure, e.g. transportation, technology and equipment, and modernizing facilities, to safely divert their attention to strengthening systems for which the infrastructure was developed. There is always space for creativity when developing and implementing system-level interventions; with this comes risk but even greater potential rewards.

Reaching the Millennium Development Goals requires an intensified focus on strengthening health systems. Effective health system strengthening depends on inter-agency consensus and country commitment along with concerted partnership.