FRONTLINE SERVICE DELIVERY

Frontline Service Delivery in Random Samples of U.S. Global Health projects in HIV/AIDS, Maternal and Child Health, Nutrition, Tuberculosis and Malaria Programs

November 2023

Our Ask: Based on the research below, our request to Congress for Fiscal Year 2025 is to have the Appropriations subcommittee that funds foreign aid ask the U.S. Agency for International Development to ensure that in the TB and Nutrition programs progress is made in obligating more of each program’s funds to projects which have as their main activity the direct provision of health services to people in the community.

Summary of Findings:

We studied 210 randomly selected USAID and State Department global health projects for which funding was obligated in FY21.  Our study found the proportion of funding in each program going to projects that mainly consisted of frontline delivery of health services was: HIV/AIDS 76%; Malaria 77%; Maternal and Child Health  65%; Nutrition 37%; TB 29%.  (For full data set contact Keith Johnson: k.johnson@fundforglobalhealth.org)

Background:

Delivery of health services to the population is a key goal of U.S. aid for Global Health programs.  We wanted to see to what extent U.S.- funded projects focused on the delivery of health services (as opposed to upstream areas such as  administrative activities) in the HIV/AIDS, Malaria, Maternal and Child Health, Nutrition and Tuberculosis programs. 

Limitations of this Study:

  1. The study is limited to publicly available data, which was found principally in USAID documents, in implementing partner reports and websites, and in internet searches.  These publicly available data are often somewhat incomplete.

  2. There was an element of judgment involved in classifying projects.  To reduce subjectivity, each project was assigned to two researchers and their findings were reviewed by Fund for Global Health supervisory staff.  In addition, we used a benefit-of-the-doubt approach:  when uncertain, we classified projects in the category with more service delivery. 

Methodology:

We drew our samples from the complete data set for FY2021 obligations for global health programs in foreignassistance.gov.  We initially studied a randomly selected set of 30 activities in each program.  The study of TB and Nutrition activities showed a much lower proportion of these projects going to service delivery compared to other areas, so to verify this result we studied an additional 30 randomly selected activities in each of the TB and Nutrition programs. 

We estimated the degree to which these projects included service delivery, based on publicly available information dated after October 1, 2020 (beginning of FY21). Service delivery components were defined according to the list below.

Available descriptions usually mentioned several components of a project without showing the proportion of funding devoted to each activity, so we used a benefit-of-the-doubt approach to estimate whether a project (a) focused mainly on frontline service delivery, (b)  included no or only minor frontline service delivery, or (c) fell into a third category in the middle. Where there was substantial uncertainty, we classified the activity in the category with more service delivery. 

The figures cited above in the Summary of Findings section refer to the proportion of funding in each program that went to projects that focused mainly on frontline service delivery.

Note: There was one exception to the random selection of projects: we excluded Global Health Supply Chain – Procurement and Supply Management (GHSC-PSM) projects because these are large-scale activities and we could not find reliable data on the extent of frontline delivery.  Because these projects are so large, we were concerned that low-quality data could skew the results.  Of the programs we studied, GHSC-PSM has components (called task orders) related to HIV/AIDS, Malaria, and Maternal and Child Health projects. It does not have components related to Nutrition or TB, so the exclusion of GHSC-PSM does not affect the data we present for Nutrition and TB. 

Frontline service delivery components:

This research defined the following as components of frontline service delivery:

  1. Frontline health workers

  2. Medicines and health supplies at service delivery points

  3. Preventive and/or curative care provided to patients

  4. Telehealth services provided to patients

  5. Behavior change communication messages provided to community members

  6. Frontline workers reporting on new threats or on their health activities

  7. Transportation of patients to point of care

  8. Lab tests for patients

  9. Provision of food and nutrients to beneficiaries 

  10. Education, e.g., teaching community members to garden for better nutrition  

We also included as frontline service delivery the following items even though they do not themselves constitute services to patients:

  1. Training frontline workers

  2. Direct supervision of frontline workers

  3. Transportation of health workers to point of care

  4. Equipment and supplies, e.g., cell phones, given to frontline workers

  5. Constructing and supplying frontline health facilities, e.g., clinics and hospitals