29 Feb 2012
This article is condensed from a newly-published
paper by the same authors entitled “The
Global Fund and Community Systems Strengthening:
The Wrong Organisation for the Right Job? Or the
Right Organisation Doing the Job Wrongly?,” which is available on the Aidspan website here.
Community
participation, of various sorts, has been at the core of many Global
Fund structures and procedures. For example, both the
Global Fund Board and country coordinating
mechanisms were designed to include civil society representatives.
In addition, community-based organisations (CBOs) and
individuals affected by the three diseases have
always occupied a central role in the delivery of
Fund-supported health programmes.
In 2009, the Global
Fund took a further step by encouraging all Round 8 funding applicants
to incorporate a more strategic and considered
approach to what it called “community systems
strengthening” (CSS) within their proposed plans and
budgets. Much time and effort has subsequently gone into the production
of guidance to applicants for incorporating CSS
activities, and into the development of indicators
for monitoring CSS.
However, the Global Fund is still not getting its approach to CSS right. We have identified three major problems.
The first one has
to do with the way CSS is conceived. When the Global Fund first
described CSS, supporting the generic systems and
infrastructure development of CBOs was a core
feature. A guide developed by the Roll Back Malaria Partnership in 2009
also described CSS in general developmental terms.
However, since then, the purpose and meaning of CSS
has changed. This has caused some confusion, but more
importantly, it appears to have progressively narrowed the scope and
focus of CSS towards supporting CBOs to improve the
uptake and coverage of selected health care services.
Important
components of CSS which do not have a direct link to health care
services (for example, building social cohesion,
promoting gender equality or fighting for human
rights and the respect of sexual diversity) are neglected. For
communities that suffer from the double burden of disease and
social discrimination or disadvantage, this is a
concern.
The second problem
relates to the way CSS is translated from what is in the proposal to
what is actually implemented on the ground. Increasingly,
Global Fund proposals are written by teams of
skilled consultants who are hired because they know
how to write winning proposals. They have learned to include
the language of community development. But, once recommended by
the Technical Review Panel (TRP) and approved by the
Global Fund Board, the proposal becomes the basis for
a negotiation between the Global Fund Secretariat and the
designated principal recipient (PR). Civil society organisations
that are selected as PRs and sub-recipients (SRs)
often have very little input in the development of
the proposal and may end up being contracted to implement a set
of activities which may or may not fit their own culture and
history of community development.
Furthermore, local
fund agents (LFAs) are playing an increasingly important role in the
negotiation of grant agreements, often to the detriment
of CSS. LFAs are organisations with variable
profiles. Some are specialised in financial audits
and others have public health expertise – but all of them work under the
restrictive terms of reference of being the Global
Fund’s “local policeman on patrol.” Not surprisingly,
therefore, their inputs in the grant negotiation
process often focus on strengthening controls and linking budgets
directly to service delivery outputs. This tends to
further restrict the scope of CSS activities
supported by the Global Fund to the delivery of service outputs that
can be counted. Activities such as networking, community
consultations or inter-generational dialogue have no
quantifiable service output, and invariably
disappear from the budget.
The third problem
is that the Fund’s approach to the monitoring and evaluation of CSS
performance is flawed due to an over-reliance on
quantitative indicators, many of which are also
poorly constructed. The
over-emphasis on quantifiable indicators frequently
results in a performance framework that is neither
specific nor valid. It also reinforces the tendency to equate CSS with
the narrow aim of supporting CBOs to help deliver
disease-based service delivery targets.
For the Global Fund
to improve its support of CSS, it needs to: (a) be clearer about what
is meant by CSS; (b) draw upon expertise from the
broader population of experts in community
development and participation; (c) reconsider its approach to
performance-based funding and management for CSS; (d) consider
how community systems can be strengthened much more
in tandem with health systems strengthening; and (e)
set up an independent commission of relevant experts to
examine how the Global Fund can support CSS more effectively and
appropriately in the future, the results of which
should feed into the 10-year evaluation of the Global
Fund.
Dr Josef Decosas (josef@hera.eu)
is a Senior Partner with HERA, an international
multidisciplinary team of professionals with
expertise in health and development research, programming, evaluation
and policy. Dr David McCoy (david.mccoy@aidspan.org)
is a public health physician and honorary senior
clinical research fellow at University College
London. He serves as a consultant to Aidspan and also works
part-time in the U.K. National Health Service.