This evaluation is the output for Study Area 3 of the Global Fund 5 year evaluation. It is a multi-country evaluation of the collective impact of the Global Fund and its partners in scaling up the response against AIDS, tuberculosis (TB), and malaria. Outputs from Study Area 1 (which evaluated the organizational effectiveness and efficiency of the Global Fund) and Study Area 2 (which focused on grant performance and health systems effects) can be downloaded from the Global Fund website. Document summaries of these outputs are also available on the GHIN database.
Significant findings are presented in this 5 year evaluation of the Global Fund - highlighting possible decline in HIV incidence rate in some countries, and rapid scale up of funding for HIV/AIDS, access and coverage; but also major gaps in support for national health information systems, and poor drug availability.
Monitoring and Evaluation
- There are major data gaps and weak health information systems (HIS) in countries that seriously limit the ability to evaluate progress. In general, the Global Fund has contributed little to strengthening country HIS, especially to Performance Based Financing (PBF) - a cornerstone approach of the Global Fund. The evaluation also reports. There is frequent shifting of indicators and targets during the different stages of the Global Fund grant. Measures of quality control by the Global Fund are not adequate.
- HIV funding increased rapidly in the 18 evaluation study countries, with 18% coming from the Global Fund.
- There has been a major expansion in access to services in all countries. However, district facility assessments in seven countries show that gaps in basic requirements such as trained personnel, guidelines, medicines, and equipment need to be addressed in order to ensure the provision of quality services
- There have been dramatic increases in estimated coverage of ART and, to a lesser extent, in HIV testing and counseling and Prevention of Mother to Child Transmission (PMTCT). In several instances, these increases tend to be larger in countries with higher levels of external funding.
- There is little evidence of large-scale changes in behaviors among most at-risk populations (primarily due to a lack of comparable representative data to allow for an examination of trends).
- Some countries show evidence of a possible decline in HIV incidence rates among young people, while survival data among people on ART are generally impressive.
- Increased funding has led to better access to care, including rapid increases in intervention uptake and notable survival benefits through ART. Evidence of changes in HIV transmission is limited, mainly due to a lack of data, the complexity of the epidemiology, and the early timing of the evaluation study.
Health systems scale up
In 2008 the Global Fund directed 35% of approximately US$4 billion of approved financing to key health systems elements. Little conclusive evidence to support or reject the hypothesis that scaling up HIV prevention and treatment have had an effect, positive or negative, on health systems and on other disease programs.
- In the 18 evaluation study countries, HIV-related external funding during 2003-2006 accounted for slightly more than 10% of total health expenditure. There is little evidence that the increase in HIV/AIDS spending has been achieved at the expense of resources for other interventions such as CMH. The extent to which the Global Fund approach of competitive-funding applications and PBF are conducive to enhancing predictable funding and continuous intervention delivery could be reexamined.
Health worker density is low in all districts, especially in rural areas. HIV scale up has focused on districts with higher health worker densities. Health system weaknesses, such as poor infrastructure and limited HR are likely to become more prominent constraints as the scale up reaches out to more districts, especially those in rural areas.
There is inadequate availability of many essential medicines, especially for chronic adult diseases but also for childhood illnesses.
- A more systematic investment and coordinated approach of all partners is urgently needed to strengthen country HIS which is the basis for monitoring progress, Performance Based Financing, and evaluation.
- Tailor prevention strategies to the type of epidemic and local context and focus on the most cost-effective interventions.
- Provide predictable funding and support to reliable ARV drug supply and distribution systems in order to build upon and expand treatment-related investments in rural and most at-risk populations.
- Address the major gaps in basic health service availability and readiness (availability of basic laboratory tests, infection control amenities, diagnostic aids, trained health workers, guidelines, and infrastructure) by supporting a health system component of disease specific grants and general HSS grants that supports country health sector strategic plans.