The Global Fund announces that the update on its plans for the new Strategy’s implementation (the ‘how’ after the ’what’) is “complicated” because it seeks to present the Global Fund’s Theory of Change (TOC), and how it will be adapted to deliver the new Strategy, in just 30 slides! This is a lot of slides by most people’s definition so in this article we have attempted to simplify the information presented. There are three areas to the implementation plan:

• The Global Fund’s TOC model. This is not new as it also described in detail in the “Partnership Enablers – How We Work” narrative section of the new Strategy. In brief, it covers the following: “We address the largest pandemic threats in the highest burden and lowest income countries by raising and investing additional funds in partnership with governments, civil society, technical agencies, the private sector and people affected by the diseases. Investments are country-owned and prioritized, rigorously and independently reviewed, implemented by local partners and managed for performance.”  Below we shall refer to this quote as the ‘underlying TOC for the Global Fund Strategy’.
• Global Fund levers and 10 key changes: This describes: (1) the “levers” that are used to deliver the new Strategy (ranging from Board policies on country funding and the design and review of funding requests (FRs) to the selection of monitoring and evaluation (M&E) activities); and (2) how the 10 changes noted in the Strategy are actually mini-TOCs that utilize these levers for achieving specific outcomes. Both levers and changes are nested within the broader TOC.
• The Global Fund’s current progress to date and thinking on delivering each of the 10 key changes, including a problem statement, three-year vision of success and major change levers proposed to achieve these changes. This section begins by reviewing the key cross-cutting themes emerging across multiple working areas.

The Theory of Change and adaption to the new Strategy

The Global Fund partnership already has a well-established and proven TOC or ‘business model’ based on the principles of country ownership, evidence-based interventions and a multi-stakeholder partnership. This is the underlying TOC for the Global Fund Strategy. The 2023-2028 Strategy describes the specific priorities of Global Fund investments vis-à-vis the actions of other partners and identifies the most important strategic areas of engagement, specific and common to the three diseases, that will accelerate the pace of program implementation and achievement of partnership-wide results. The new Strategy refines the underlying TOC to articulate and plan how Global Fund actions, efforts and investments, working in partnership with others through a series of ‘levers’ can put greater emphasis on certain elements to accelerate progress, enhance impact and ensure sustainability of investments. Progress through the change pathways is regulated by the Global Fund’s successful application of its levers as part of Strategy delivery and is based on a set of underlying contextual assumptions and enablers, including the clear roles and accountabilities of partners. The interconnected change pathways are interlinked to the achievement of medium- and long-term outcomes that in turn advance impact as defined by the Strategy. The Global Fund teams have been using the TOC logic as they focus on the 10 Key Changes identified by the new Strategy and informing Strategy delivery efforts. Finally, the TOC will also guide the development of the Strategy’s M&E Framework by informing the key questions and insights for which data are required to measure progress in the 10 change areas and the achievement of outcomes, as well as to prioritize the most important measurement areas for Strategy-level key performance indicators (KPIs). Area 1: The Global Fund’s TOC Model: Setting the scene Let’s start by reminding ourselves that that the TOC is built on the Strategy Framework approved by the Board in 2021.

Figure 1. The Approved Strategy Framework

The TOC attempts to present the ‘how’: how the primary goal, and its five objectives (the three “mutually reinforcing contributory objectives”, the cross-cutting objective and the one “evolving objective”), called Strategic Objectives (SOs), will be actioned. The context for the TOC, the environment in which it will be delivered, is shown in Figure 2 which depicts how the Global Fund and its partners seek to address the largest pandemic threats in the highest burden and lowest income countries. This will be achieved by raising and investing additional funds in partnership with governments, civil society, technical agencies, the private sector, and those affected by the diseases. As noted, “investments are country-owned and prioritized, rigorously and independently reviewed, implemented by local partners and managed for performance.”

Figure 2. The Context for the Global Fund Theory of Change

* Funding breakdown from Global Fund 2020 Results Report.

Within the broader health ecosystem, the TOC differentiates the Global Fund’s work from other essential global health actors and functions, such as the World Health Organization (WHO)’s leadership role on norms and standards, UNITAID’s on accelerating upstream innovations, and Gavi’s on vaccination. I hope this is clear so far. Area 2: Global Fund Levers and 10 Key Changes Figure 3 represents the five components of the TOC ranging from Inputs through Activities, Outputs, and Outcomes, and finishing with Impact. These five components are represented by the different colours used in the diagram below.

Figure 3. The Underlying Theory of Change

Theory of Change Levers The “levers” in the Global Fund context are the key aspects of the Global Fund model that can be used and adapted to drive and shape investments and progress in key areas of the Strategy. They range from what the Fund allocates funds for, to what it asks countries to prioritize in FRs, to how it manages the prioritization and performance of investments.

Figure 4. The Six Levers and illustrative examples of what they include

In fact, these six Levers are really the TOC’s second component, the Activities. Figure 5 illustrates how the six Levers — (i) Raise funds, (ii) Policies for allocation and sustainability, (iii) Grant design, review and approval, (iv) Sourcing operations, (v) Implementation mechanisms, and (vi) Performance management — will be “enabled”, or operationalized, by “partners with clear roles and accountabilities”. How the model is applied to a change pathway The Global Fund then provides an example (under Figure 8) of how a Key Change area reinforces the underlying TOC for Strategy delivery. For each of the 10 Key Changes or change pathway headings, there are vertical columns as follows:

1. The six inputs/Levers (in general), which feed into —
2. — the detailed Levers (a more detailed description of what will happen under each applicable Lever which may be all or some of the six). This feeds into —
3. The four Activities and Interventions (or what I call strategies).
4. Preliminary “work areas” under the appropriate Activity/Intervention.
5. The three-year preliminary vision of success.
6. The six-year vision of success (Immediate Outcomes)
7. Long-term outcome. And finally, to the —
8. Impact.

(Sigh of relief. But not so quick…) How does this work in practice? Using Change Pathway 5 — Intensified action to address inequities, human rights and gender-related barriers — as an example, while all four Activities and Interventions apply the most important of these is the third (To tackle the socio-economic determinants of HTM, including human rights related barriers, gender inequalities and other inequities); accordingly, under this strategy the applicable work areas are described as:

• Refine Global Fund role and support to Human Rights (HRts), Gender, & Equity to create better health outcomes for the three diseases.
• Enhance quality & scale of programming related to HRts, Gender Equality, & Health.
• Equity within HTM: Enhance domestic engagement with a multi-sector approach.
• Enhance quality & scale of programming related to HRts, Gender Equality, & Health Equity within HTM: Improved policies & processes within the Secretariat.

Figure 8. Example of how key change area 5 reinforces the underlying Theory of Change for Strategy delivery

  Phew! Now: how does this fit back with the Strategy? The “Strategy Delivery” process The “Strategy Delivery” process uses a TOC logic in planning for critical change areas identified in the Strategy

Figure 9. Strategy delivery process, work areas, levers and outcomes/goal

This is taken directly from the Strategy Narrative approved by the Board in November 2021. The Secretariat then goes on to describe the preliminary themes that are emerging across Key Change working/discussion groups within the Global Fund and partners: Directiveness: There is an overall higher appetite to be more directive in critical areas for impact (both from SC and Secretariat) while respecting country ownership. This can utilize levers – like the Grants Approval Committee (GAC)/Technical Review Panel (TRP) review, catalytic investments, allocation letters, FR forms – to drive the right types of decisions and provide the necessary process to flag and discuss where countries are not funding the most impactful interventions. (All groups) Quality Standards: Setting quality standards (including recommended tools, products, program elements, best practices) as part of funding applications is a major way to improve quality while maintaining country ownership. Quality standards must be set in advance of the FR review processes and aim to influence upfront portfolio analysis and country dialogue instead of waiting until FR review. (Incidence Reduction: HTM, Accelerate equitable intro/uptake of new tools/innovation, Voice for Communities) Funding request/grant-making launch: The FR/grant-making process (e.g., FR template, technical guidance, allocation letter, etc.) is a major change lever for most Key Changes but must be targeted and balance magnitude of changes that can be digested and reflected at country level in this grant cycle. (All) Country Coordinating Mechanisms (CCMs) and Country Dialogue: Changing CCM representation or changing/expanding country dialogue are coming up frequently as change levers. There is a need to consider how much CCMs can take on board and how it will be translated at country level. (Incidence Reduction: HTM; People-centred Integrated Services for Health (PCISH); Service Delivery by Community-Based and Community-Led Organizations (CBO/CLOs); Voice for Communities; Health Equity/HRts/Gender; Pandemic Preparedness) Health financing (HF): HF and co-financing are critical for delivering aims across the Global Fund mission and particularly for increasing coverage of effective interventions. There needs to be an “all-Partnership” effort to emphasize increasing total available HF in the next round of grant negotiation/approval and mainstreaming of HF elements in disease and grant discussions. (All groups) Data: Every WG has identified increased data needs (e.g., new indicators, sub-national data, HF data, analytical capacity, etc.) for better decision-making and resource allocation. It is important to clarify for whose benefit and there is a need to balance this with countries’ capacity and capability to collect reliable data. It is a potential major driver of operating expenses for the next strategy cycle. (All groups) Area 3: Current progress to date and thinking on delivering each of the 10 Key Changes Several slides follow, each a Work in Progress Summary for:

• TB Incidence Reduction
• HIV Incidence Reduction
• Malaria Incidence Reduction
• Service Delivery by CBO/CLOs
• Voice for Communities
• Health Financing
• Health Equity, Human Rights and Gender Equality
• Accelerate Equitable Introduction & Scale Up of New Tools & Innovation
• People-centred Integrated Systems for Health
• Pandemic Preparedness

These are similar to, but not the same as, the ten Key Changes discussed earlier. It is unfortunate that there are the same number of each, as this is another potential area for confusion. Each Work in Progress Summary includes a problem statement, the work area’s scope, the three-year vision of success, preliminary work areas and preliminary change Levers. Strategy implementation preparation on data and partnerships remains at an early stage as its content is largely derived from, and in support of, other Key Changes. The decisions and action needed to launch the next cycle of grants are shown in Figure 10.

Figure 10. SC/Board decisions and related Secretariat actions needed to launch the next cycle of grants

Commentary You can see from the foregoing how complex the implementation will be, and one has to admire the tenacity of the Secretariat for its perseverance and determination in trying to unpack all the various interlinkages and steps necessary to deliver the ambitious Strategy. Nonetheless, you can also see why stakeholders are struggling to get their heads around what this all means. As you know, we like to simplify things where possible. But this has been a tall order when it comes to these implementation plans. We hope that our attempts to provide a ‘101’ or crash course in the ‘hows’ of the Strategy has been successful and that you do not finish this reading this article and immediately reach for the headache pills!