The Global Fund spends millions each year on products and services and depends on accurate and reliable information to ensure its investments generate the desired outcome—improved health. Without this information, the Global Fund is unable to make sensible funding decisions or measure a program’s impact.
With billions spent on global health each year, the most important thing to verify is results, not receipts.
Consider a program to treat malaria. The Global Fund could ensure that the right amount of nets is purchased at the lowest possible cost and delivered to a country in an efficient manner. Yet these efforts would all be for naught if the nets sat unused in a warehouse or were improperly used.
Verifying performance accurately is essential to ensure that products and high-quality health services reach their intended beneficiaries, and to hold recipients of funding accountable for improving health.
Current Limitations of Verification
The Global Fund places a high priority on data collection and has a range of policies and procedures that aim to improve the accuracy and reliability of information. But data quality remains a concern for several reasons.
First, the Global Fund relies on self-reported data from grant recipients that may not accurately reflect improvements in health. The incentive to report the “right” results may override any incentive for accuracy, especially when future funding hangs in the balance, as is the case with the Global Fund’s current performance-based financing mechanism. Such self-reported data are subject to only cursory checks for accuracy and quality as recipients often lack the mandate, resources and staff capacity for more credible and rigorous verification.
Second, the reports with which the Global Fund verifies performance don’t usually capture the coverage and outcomes of interventions. A recipient could accurately report itself (and thus be verified) as having distributed a given number of bed nets to households in high-transmission areas, but omit (or be unaware) that nets had been misused as fishing equipment or soccer nets. Without a presence on the ground, the Fund can’t confirm if investments have led to better health outcomes and coverage.
Finally, the Global Fund supports many innovations in service delivery, or strategies that have not been tested in terms of their impact on coverage and health. Impact evaluations could help the Global Fund clearly isolate the effect—or lack thereof —of innovative delivery strategies and interventions.
Self-reported data are good for local management decisions, but they are not good for policy decisions.
Executive Director of National Health Systems Resource Centre in New Delhi
Part of the Solution: More Rigorous Independent Verification
More rigorous and representative verification could help the Global Fund grapple with the challenges of assessing performance. Verification should remain independent, but the function should be shifted away from the Local Fund Agent – generally auditors – towards organizations with capacity to conduct rigorous and representative verification. Many organizations can undertake independent verification and measurement including a local polling or consulting firm, a national statistics office (if independent), or a research group or NGO.
The benefits of independent verification are many: it can create accountability for health service delivery and encourage a national dialogue on results; it can improve the quality of administrative data and strengthen monitoring and evaluation systems in recipient countries; and it is crucial for ensuring that the Global Fund has an accurate assessment of the health returns to its financial investment in the absence of on-the-ground staff. In turn, accurate data assures that performance-based payments reward real improvements, rather than administrative reporting errors or intentional manipulation.
Still, there are a number of concerns about increasing the use of independent verification and measurement at the Global Fund. Some worry that it will undermine a country’s sense of ownership over health programs and efforts to strengthen national health systems as a whole. But independent verification doesn’t have to be conducted by foreign entities. Often local NGOs or research groups are well-equipped to serve this role. Others worry about adding additional checks and paperwork to the already extensive Global Fund grant management framework, which is a real concern. But with millions of dollars spent each year on programs to improve health, the most essential “check” of all should be their final impact on health.
Without strong data verification, the Global Fund is unable to make sensible funding decisions or measure a program’s impact.
Finally, for many interventions it is difficult to find good baseline information against which to measure future progress. Without knowing the current level of coverage or retention, it isn’t possible to assess marginal improvements. Where this is the case, measurement during the first round of the New Funding Model can serve as the baseline for the second three-year grant cycle, at which point performance-based financing can be fully implemented.
Conceptually, different approaches to assessing grant performance span a continuum: at one end, the grant recipient does all the measurement without any external checks to verify accuracy; at the other, the health funder would assess performance exclusively with independent measurement. In practice, funding agencies usually fall somewhere in the middle.
The Global Fund’s current approach lies toward the left end of the spectrum, where self-reports from recipients are subject to only cursory checks for accuracy and data quality. While there is no one right approach to performance verification, the Global Fund should take the following steps to move rightward along the spectrum.
Approaches to Assessing Grant Performance
Define a Minimum Set of Core Indicators for Independent Verification
The Global Fund should drastically reduce the number of performance indicators by excluding input and output indicators (number of bed nets or condoms distributed), and instead focusing on key health-care coverage and outcome indicators (coverage and retention of ART). Ideally, these indicators will be based on existing scientific evidence and show a clear link between an intervention and health impact. Progress against these indicators should be regularly verified across all grants.
Accurate data assures that performance-based payments reward real improvements to health.
Scale Up Independent Verification to Check the Accuracy and Quality of Self-Reported Results
The Global Fund should set standards for rigorous and representative performance verification, and provide funding for a qualified independent entity, or Local Performance Agent (LPA), to carry out verification on a few of the most essential self-reported program indicators. Information from these checks would help inform funding decisions during the Fund's regular disbursement process, includig those disbursements made via their performance based financing scheme.
Verification will fall into two broad categories depending on the type of program: clinic-based services and community- or population-based services. For clinic-based services, verification could entail a mix of unannounced on-site data audits at a representative sample of facilities, assessments of service quality and readiness (measuring stock-outs and absenteeism, for example), and interviews with a significant sample of reported program beneficiaries. Where possible, the Global Fund should piggy-back on existing verification efforts such as the President’s Malaria Initiative’s end-use verification of facilities that receive joint support, or the World Bank’s Health Results Innovation Trust Fund in participating countries. For community- or population-based programs (including bed net or condom distribution and behavior change), verification should include a representative annual mini-survey within the target population to assess service coverage and effects to ensure, for example, that people in the targeted community are using bed nets correctly.
Pair Verification with Population-Based Measurement and Formal Impact Evaluation
The Global Fund should pair its regular verification efforts with population-based measurement once per three-year grant, timed to coincide with grant negotiations for the next funding cycle. This would help the Fund measure coverage of key health services among the target population and assess the health trends in that populations that could be connected to Global fund investments. At times, a tailored survey may need to be commissioned. But where possible, the Global Fund could piggy-back on existing population-based measurement exercises, such as the Demographic and Health Surveys. The Global Fund should use formal impact evaluations for new or unproven interventions to determine if they are effective and cost-effective. If so, the Global Fund can expand its eligible interventions list to reflect the evolving evidence base. By doing so, the Global Fund can both support new ideas and innovative strategies, while also ensuring that its resources primarily fund interventions that are proven to save lives or prevent new infections.