Phase 1: Desk review and process definition
Based on the relevant documents available, the process that a country has to follow to implement a programme with funding from the Global Fund was depicted. The ideal insertion point for OR implementation was identified to be within the phase prior to the submission of proposals to the Global Fund, especially during and after the country’s needs assessment. The ‘opportunity ownership’ was also assessed. It means that any action towards OR implementation has to be initiated by the owner of the opportunity, otherwise a conflict may appear. The process depiction, opportunity ownership and the OR specific insertion points throughout the grant life process are shown in Fig. 1. Twelve stakeholders were interviewed to crosscheck the accuracy of the process depiction, insertion points’ identification, and opportunity ownership.
Country visits
Visits took place to Ghana, Sierra Leone and Zimbabwe, whereas Tanzania was assessed via telephone due to conflicting agendas between the study timelines of the mandate and the availability of the local stakeholders. The number of stakeholders interviewed were 21 in Ghana, 11 in Sierra Leone, 4 in Tanzania and 18 in Zimbabwe. During the country visits we identified the key stakeholders involved in the ‘prior to submission’ phase as the Ministry of Health (MoH), the Country Coordination Mechanism (CCM), the national control programme managers, local and international technical partners and research organizations, civil society representatives, and non-governmental organisations (NGOs). The involvement of the stakeholders varied from country to country suggesting that their involvement is not always fully assured. For instance, some interviewees mentioned that they “…develop the needs assessment in a participatory way through country dialogues”, whereas others mentioned that “the needs agenda is imposed by the Ministry of Health”.
Role of stakeholders
The interviewed stakeholders perceived the CCM as a coordinating force whereas, the MoH was perceived as a multifaceted player steering implementation, advisory, technical assistance and needs assessment. Several stakeholders mentioned that CCM has the advantage “of not being under the governments’ payroll, so they can be objective and are not afraid of pointing out mistakes”. The Global Fund was identified as the most influential stakeholder able to provide normative guidance on the integration of OR in the countries.
OR demand
We identified that the concept of OR is not homogenous among the countries nor the stakeholders. Regarding the SORT IT programme, only a few stakeholders knew the programme or similar tools to acquire OR skills.
Although efficiency on both programme implementation and use of resources was mentioned thoroughly across stakeholders and disease programmes, the donors, CCM or high-level government authorities did not articulate concrete demands in this regard. Some stakeholders mentioned that they “do not feel a strong pressure from Global Fund to optimize efficiency”, a perception that has been previously described in other studies [21–23]. The status quo of the programmes funded by the Global Fund did not commonly include OR.
Behaviour change assessment
According to the COM-B [13] and Fogg’s behaviour models [14], a certain behaviour will manifest in a given moment when there is opportunity, a motivating factor, capability and triggers to do something.
Opportunity
The countries have several opportunities to integrate OR into the Global Fund funded programmes (Fig. 1). For instance, they can identify OR specific training in their needs assessment or they can add it to their National Strategic Programmes.
Motivation
The stakeholders of Global Fund grants – including programme implementers – have shown a positive attitude regarding any effort oriented to optimize the efficiency of Global Fund investments. However, the search for increased efficiency is a desire that may not currently materialize because the dialogue with the Global Fund and/or national stakeholders does not include metrics or incentives that reflect accurately the value for money [24–26]. Consequently, any effort oriented to increase efficiency has a lower priority when compared with the implementation of activities.
Capability
As pointed by Kiefer and colleagues [11], the current study confirmed that in each of the investigated countries there are several academic institutions (both national and international) and NGO’s present with research experience and expertise and the capacity to develop OR. However, partnerships to implement OR within the disease programmes are not flexible nor aligned to a national research agenda, except in a few cases. Given the weaknesses in the countries’ capabilities, the OR implementation partners within countries would benefit from capacity strengthening interventions such as SORT IT. For example
a) The acquired capacities will be available to the whole health system and not only to the programmes supported by the Global Fund;
b) Being external to national disease control programme implementers, it may provide them with a more holistic and independent perspective about the performance of the programmes;
c) By assembling OR capacities in as few single units as possible, instead of simultaneously in three programmes, the efforts to strengthen capacities in OR could be more efficient.
Triggers
Programme reviews can act as triggers and they should be targeted by any initiative oriented to increase of OR/IR in Global Fund-supported grants.
Given that all the behavioural aspects are present in the studied countries, this suggests that the inaction to implement OR is due to either aspects other than behavioural ones or to a possible block of action from an influential stakeholder.
Force-field analysis
Multiple forces favouring OR inclusion in Global Fund supported programmes were identified. The assistance from the different CCM members and their confidence to influence MoH seemed to be a key opportunity to be taken on board. In addition, civil society organizations, project managers, academia and international donors with presence in the countries (e.g. World Bank in Ghana) manifested their willingness to support OR implementation, as long as they were to be involved in the process and the trainings aim at sub-national level. On the other hand, forces opposing OR inclusion in Global Fund funded programmes were identified as follows: in face of the scarcity of funding, tangible goods (e.g. drugs or supplies) or well-known activities (e.g. training of health workers in case management) are commonly prioritized over OR. In addition, the uncertainty about the practical value of OR, does not generate the interest to search for extra funding to develop this niche activity. Any additional funding would be used, in a first instance, to procure the tangible goods, such as medicaments or bed nets, unless they are not specifically earmarked for OR.