lev-os Managing Global Health Programs
Why This Skill Exists
Global health programs operate at the intersection of epidemiology, diplomacy, economics, and cross-cultural implementation science. The institutional architecture — WHO, UNICEF, The Global Fund, Gavi, PEPFAR, USAID, World Bank — each has distinct governance, funding mechanisms, reporting requirements, and technical frameworks. The International Health Regulations (IHR 2005) establish the legal framework for cross-border health security. The Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-Being), set the outcome targets. WHO GOARN (Global Outbreak Alert and Response Network) provides the emergency response coordination mechanism. Programs must navigate low-resource settings, fragile health systems, complex supply chains, and diverse cultural contexts — all while maintaining rigorous M&E (monitoring and evaluation) standards. This skill structures the management of global health programs from design through evaluation, grounded in the frameworks that govern international health cooperation.
Checkpoint A — Intake and Scoping
Intake Questions
- What is the health focus — infectious disease control (HIV, TB, malaria, NTDs), maternal/child health, immunization, nutrition, NCD prevention, health system strengthening, or emergency response?
- Which country/countries are in scope? What is their WHO region, income classification (World Bank), and UHC service coverage index?
- Who is the funding entity — USAID, Global Fund, Gavi, PEPFAR, World Bank, bilateral donor, foundation?
- What is the implementing model — direct implementation, technical assistance to Ministry of Health (MOH), sub-granting to local NGOs, or multilateral coordination?
- What is the program phase — design, startup, scale-up, maintenance, or closeout?
- What country-level health policies and national health strategic plans are relevant?
- What IHR (2005) core capacities are relevant (surveillance, laboratory, risk communication, response)?
- What M&E framework is required by the funder (Global Fund Performance Framework, PEPFAR MER indicators, USAID results framework)?
Required Documents
- Country health profile (WHO Global Health Observatory data, DHS/MICS surveys)
- National health strategic plan and disease-specific national plans
- Funder's program guidance and results framework (PEPFAR COP guidance, Global Fund modular framework, USAID CDCS)
- IHR (2005) Joint External Evaluation (JEE) report for the country
- WHO clinical and program guidelines relevant to the health focus
- Prior program reports and evaluations
- Stakeholder mapping including MOH counterparts, implementing partners, and community organizations
- Country-specific ethical review requirements (national ethics committee, IRB)
Step 1 — Conduct Situation Analysis
Assess the health landscape in the target country:
- Disease burden: Compile country-level epidemiologic data — incidence, prevalence, mortality for the target conditions. Sources: WHO GHO, IHME Global Burden of Disease, DHS (Demographic and Health Surveys), MICS (Multiple Indicator Cluster Surveys), national surveillance data.
- Health system capacity: Assess using the WHO health system building blocks:
- Service delivery: Facility density, service availability (SARA survey data), quality of care indicators.
- Health workforce: Physician/nurse-to-population ratio, community health worker (CHW) programs, training capacity.
- Health information systems: DHIS2 implementation, vital registration completeness, surveillance system functionality.
- Medical products/technologies: Essential medicines availability, supply chain maturity, cold chain infrastructure.
- Financing: Total health expenditure per capita, out-of-pocket spending share, donor dependency ratio.
- Leadership/governance: National health policy framework, regulatory capacity, coordination mechanisms.
- IHR core capacities: Review the Joint External Evaluation (JEE) scores for surveillance, laboratory, preparedness, response, and risk communication. Identify gaps.
- Social and cultural context: Gender norms, health-seeking behavior patterns, traditional medicine use, community power structures, stigma around target conditions, language diversity.
Step 2 — Design the Program with Country Ownership
- Align program design with the country's National Health Strategic Plan and disease-specific national plans. External programs that operate parallel to country systems undermine sustainability.
- Apply the Paris Declaration principles: ownership (country-led priorities), alignment (use country systems), harmonization (coordinate with other donors), results (measure outcomes, not just outputs), mutual accountability.
- Design the results framework:
- Goal (long-term impact): Aligned with SDG 3 targets and national targets.
- Purpose/Outcomes (medium-term change): Measurable changes in coverage, quality, equity, or health status.
- Outputs (program deliverables): Services delivered, systems built, capacity developed.
- Activities: Specific interventions mapped to outputs with implementation timelines.
- Indicators: For each level, define indicators with baseline, target, data source, frequency, and responsible party. Use standard indicator sets (PEPFAR MER, Global Fund standard indicators, WHO 100 Core Health Indicators).
- Apply WHO normative guidelines for clinical interventions. Do not deviate from WHO-recommended treatment protocols unless justified by country-specific drug resistance data or regulatory context.
- Include a sustainability and transition plan from the outset: how will program activities be absorbed by the MOH or local partners when external funding ends?
Step 3 — Implement with Quality and Equity
- Work through and strengthen existing country health systems (health facilities, CHW networks, supply chains, HMIS) rather than creating parallel structures.
- Implement WHO-recommended interventions adapted to the local context:
- HIV: Test-and-treat per WHO guidelines, differentiated service delivery (DSD) models, viral load monitoring, prevention (PrEP, VMMC, PMTCT).
- TB: Active case finding, rapid molecular diagnostics (GeneXpert), DOT/video-DOT, contact investigation, drug-resistant TB treatment per WHO regimens.
- Malaria: ITN (insecticide-treated net) distribution, IRS (indoor residual spraying), seasonal malaria chemoprevention (SMC), ACT treatment, RDT diagnostics.
- MCH: Focused antenatal care (FANC), skilled birth attendance, EmONC (emergency obstetric and newborn care), postnatal care, immunization (EPI schedule per Gavi).
- Health system strengthening: DHIS2 deployment, supply chain optimization (mSupply, OpenLMIS), CHW training and supervision, quality improvement (QI) collaboratives.
- Ensure equity in service delivery: disaggregate coverage data by wealth quintile, urban/rural, gender, age, and geographic region. Design specific strategies for hardest-to-reach populations.
- Apply ethical standards: national ethics committee approval for all research activities, informed consent processes adapted to local literacy and cultural context, community engagement and benefit-sharing.
Step 4 — Monitor, Evaluate, and Learn
- Routine monitoring: Establish a data flow from health facilities → district → national HMIS (typically DHIS2) → program M&E team. Define reporting frequency (monthly for service data, quarterly for program reports, annually for outcome data).
- Data quality assurance: Conduct quarterly RDQA (Routine Data Quality Assessments) comparing facility registers to HMIS reports. Calculate verification factors and consistency ratios.
- Funder reporting: Meet all funder reporting requirements:
- PEPFAR: Quarterly MER (Monitoring, Evaluation, and Reporting) indicator submissions through DATIM.
- Global Fund: Semi-annual Progress Update and Disbursement Request (PUDR) with programmatic and financial data.
- USAID: Quarterly and annual performance reports per the award agreement.
- Evaluation: Plan for mid-term and end-of-program evaluations. Use mixed methods: quantitative impact assessment (DHS comparison, health facility surveys) combined with qualitative implementation research (process evaluation, most significant change stories, realist evaluation).
- Learning agenda: Establish a structured learning agenda with questions the program needs to answer to improve implementation. Conduct operational research and disseminate findings through peer-reviewed journals and global health forums.
Step 5 — Plan for Sustainability and Transition
Sustainability planning begins at program design, not at closeout:
- Financial sustainability: Work with MOH on domestic resource mobilization — integration of program costs into national budgets, insurance coverage, and co-financing arrangements.
- Technical sustainability: Build local capacity through training-of-trainers, mentorship, south-south learning exchanges, and gradual transfer of technical leadership from international to national staff.
- Institutional sustainability: Integrate program activities into existing government structures — national guidelines, supervision systems, supply chains, and quality assurance mechanisms.
- Transition plan: Develop a phased transition timeline (typically 2-3 years before program end) with milestones for responsibility transfer, budget absorption, and capacity benchmarks.
- Community sustainability: Strengthen community-level structures (village health committees, patient support groups, CHW networks) that can sustain community-level activities without external funding.
Checkpoint B — Program Review
- Situation analysis completed with country-specific burden, system capacity, and context data
- Results framework aligned with national health strategic plan and funder requirements
- WHO normative guidelines applied for all clinical interventions
- Implementation delivered through country health systems (not parallel structures)
- M&E system functional with routine data quality assurance
- Funder reporting requirements met on schedule
- Equity analysis conducted — coverage disaggregated by key strata
- Sustainability and transition plan documented with milestones and timelines
Quality Audit
- Country ownership demonstrated — MOH co-leads program design and governance
- IHR core capacity gaps addressed where relevant to program scope
- Indicators use standard definitions (WHO, PEPFAR MER, Global Fund) with documented metadata
- DHIS2 or equivalent HMIS data validated through RDQA with verification factors > 90%
- Drug and commodity supply chains use WHO prequalified products
- Ethical approvals obtained from national ethics committee and all institutional IRBs
- Gender analysis conducted and gender-responsive strategies integrated
- Transition readiness assessed at least annually using a structured scorecard
Guidelines
- Country ownership is not a slogan — it is the primary predictor of program sustainability. Programs designed by international staff in headquarters and imposed on countries will not survive funding transitions.
- WHO guidelines are the normative standard for clinical practice in global health. Deviating from WHO recommendations requires documented justification (national drug resistance patterns, regulatory constraints, or published evidence from the specific country context).
- IHR (2005) compliance is not optional for WHO Member States. Global health programs should strengthen — not circumvent — national IHR capacities (surveillance, laboratory, reporting, response).
- Data colonialism is a real risk: extracting data from low-resource countries for publications and career advancement without building local analytic capacity and ensuring community benefit is ethically unacceptable. Prioritize local authorship, data ownership, and capacity building.
- Security and duty of care for program staff (both international and national) must be addressed explicitly in fragile and conflict-affected settings. Follow the Saving Lives Together framework for UN-NGO security coordination.
- Currency and commodity price fluctuations can devastate program budgets in low-income countries. Build contingency into budgets and maintain relationships with procurement agencies (UNICEF Supply Division, Global Drug Facility, Global Fund Pooled Procurement Mechanism).
- Escalate to program director or funder representative when: a disease outbreak threatens program operations, host government policies conflict with evidence-based practice, security conditions deteriorate, or a significant adverse event occurs in program participants.