Structured Abstract
| Document Title: | Common Research protocol. Monitoring and Evaluating the health system-Wide Effects of the Global Fund to Fight AIDS, Tuberculosis and malaria. November 2003. |
| Institution: | Systemwide Effects of the Fund (SWEF) Research Network. |
| Authors: | not mentioned |
| Study funded by: | not mentioned |
| Objectives: | to document the effects of the processes involved in applying for and receiving a Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) grant, and implementing Global Fund supported activities, on the health care systems of recipient countries. |
| Methods: | This common research protocol is meant to serve as a guide to country teams as they begin to develop country-specific protocols.
The proposed study is focused on
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Executive summary (authors')
The research aims to:
Document the effects of the processes involved in applying for and receiving a Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) grant, and implementing Global Fund supported activities, on the health care systems of recipient countries.The results will be used to derive lessons for:
- Stakeholders in countries receiving Global Fund grants, so as to inform policies and implementation strategies for Global Fund-supported activities
- The Global Fund Board and Secretariat, so as to help improve Global Fund processes and guidelines in order to ensure that Global Fund-supported activities enhance broader health care systems;
- The broader donor and global community regarding how best to channel efforts to scale up substantially the assault upon AIDS, Tuberculosis (TB) and malaria and other diseases of poverty in low and middle income countries.
- Process effects upon the functioning of the health care system;
- Measures of health system performance such as equity, efficiency, access, quality and sustainability of non-focal services;
- Impacts upon utilization of services and coverage of non-focal diseases; and,
- The burden of disease from non-AIDS, TB and malaria illness.
The study will focus upon four thematic areas, namely:
- Effects upon the policy environment - Global Fund proposal and planning processes are designed to enhance the range of actors involved in informing policy and implementing disease control activities. The study will assess the extent to which this occurs. The development and implementation of Global Fund supported activities interfaces with other planning and aid frameworks such as SWAps and PRSPs, as well as other new financing mechanisms (such as MAP) targeted at HIV/AIDS. The study will assess the effect of Global Fund support upon the broader pattern of health system funding, and the extent to which the policy and operational pursued by the Global Fund are in alignment with existing structures.
- Effects upon the Public/Private Mix - The Global Fund explicitly welcomes innovative approaches to expanding service coverage and approaches that draw private sector actors into the health care system; accordingly a greater role for private sector actors may evolve. The study will evaluate the effects of Global Fund support upon the number, distribution and organization of different types of providers (public, private for-profit, private non-profit) and relationships between public and private sectors (such as the number of public/private partnerships in non-focal areas, and the degree of trust and cooperation between sectors). In addition, the study will explore the implications of these changes for overall health system performance.
- Effects upon Human Resources - Many Global Fund proposals include training activities for health workers, and some address issues of staff retention and motivation. Where health workers are in short supply, Global Fund supported-activities may overburden capacity. Global Fund-supported activities may also affect the skills, motivation and distribution of health workers, and may cause shifts in the distribution of health workers from non-focal disease programs/functions. The study will evaluate the extent of these effects, and identify the mechanisms through which they were affected.
- Effects upon Pharmaceuticals and commodities - Approximately 50 percent of Global Fund money already committed will procure pharmaceuticals and commodities. This injection of funding may affect procurement, supply and distribution systems, and the quality and prices of other drugs and commodities. The study will use the drug management framework (procurement, distribution, utilization/rational use, and monitoring and evaluation) as well as the access framework (geographic access, physical availability, financial affordability, quality and specific issues of pricing/subsidies) to investigate the effects of the Global Fund upon pharmaceuticals and commodities.
Short-term monitoring of systemwide effects, will allow researchers to provide initial findings in a timely manner to in-country policymakers and decision makers. Short-term monitoring will draw upon a variety of data sources including document review, in-depth interviews and focus group discussions, facility surveys at sentinel sites and routine information systems. A table of suggested indicators that might be used for short-term monitoring is provided.
The longer-term evaluation will complement the shorter term monitoring by providing more reliable, statistically significant and nationally representative findings. The centerpiece of the longer-term evaluation will be a nationally representative facility survey (based upon the Service Provision Assessment tool developed by MEASURE DHS) that will collect information about staffing, service availa bility, medicines etc. Other surveys, such as human resource surveys, policy process surveys may be added by study countries.
Special studies may be pursued in a sub-set of countries to examine, for example, quality of care, health worker allocation of time, health worker motivation, and financial studies of additionality.
Given the fact that Global Fund supported activities are likely to spread across a whole country, there will not be any control group for evaluation, and it will be difficult to establish the counterfactual for evaluative purposes. Country researchers need to track Global Fund supported interventions closely, and hypothesize what their effects will be in order to be able attribute effects observed in an appropriate manner.
This common research protocol is meant to serve as a guide to country teams as they begin to develop country-specific protocols. It is proposed that appropriate steps in adapting the protocol to countries are as follows:
- Identify the most appropriate way to delimit the intervention of interest to be examined in this study? In general, Global Fund supported activities constitute the intervention of interest, but if Global Fund funding is being used jointly with an additional funding source, then it is probably most appropriate to consider the systemwide effects of the combined funding.
- Review proposed processes and activities to be supported by the Global Fund at the country level, and develop hypotheses about the likely consequences of these upon the health care system.
- Conduct a baseline assessment - to address the question of "What does the situation, with respect to policy processes, human resources, public/private mix or pharmaceuticals, look like prior to the arrival of the Global Fund?"
- Track the actual implementation of Global Fund supported processes and activities over time, to identify what actually gets implemented.
- Conduct follow-up monitoring, studies and evaluations to determine the effects of theGlobal Fund upon the health care system. Use the information garnered from all the different steps above to determine:
- Which of the effects observed can be legitimately attributed to the Global Fund intervention?
- Why did these effects occur?
