The fifth Community, Rights and Gender Report was presented to the 41st Global Fund Board Meeting this week in a ‘Pre-Day’ session on May 14. The report appears light on metrics (though these are reported through Strategic Performance Reporting) and heavy on themes, which could reinforce some conceptions that progress made in this line of work is hard to quantify and that it is therefore difficult to examine results and determine value-for-money. Nonetheless, the 22-page report does outline how the Fund approaches this multi-faceted aspect of its work, and highlights a slate of case examples, in addition to including detailed key performance indicator results in the annexes, for those seeking quantifiable evidence.
The report states that the Secretariat is “systematically reflecting on how the Global Fund can apply a community, human rights, gender and key populations lens to all aspects of its work”. It describes how the Global Fund operationalizes its commitment to community engagement and systems, and to promoting human rights and gender equity, including through the $15-million, three-year Community, Rights and Gender Strategic Initiative (CRG-SI).
The strategic initiative, which is implemented through long-term capacity building and short-term technical assistance programs, as well as regional coordination platforms, is perhaps a beacon of the Global Fund’s CRG work, which is headed by Kate Thomson. But, Thomson told the GFO, the CRG-SI, per se, “represents only a fraction of what the Global Fund is doing to advance these different areas.” Other key mechanisms for advancing community engagement, human rights, and gender equity include catalytic and matching funds opportunities for some country grants, and internal and external partnerships with a range of departments at the Fund, and organizations working at global, regional, and national levels, among others.
In this article we summarize the key points of the CRG report to the Board.
‘Leaving no one behind’
For the Global Fund, “leaving no one behind” in the responses to HIV, TB, and malaria is more of a guiding principle than a specific initiative – but it is central to its role in “advancing and reinforcing Universal Health Coverage (UHC) and progress towards the Sustainable Development Goals (SDGs),” according to the CRG Report. This includes understanding where service gaps or barriers are, and developing and deploying targeted solutions. As examples of what the Fund is doing in this regard, the report offers six short case studies that illustrate its focus on “investments in the right places for the right people so that no one is left behind”.
One such example is the Fund’s investments in South Africa focusing on integrated, multi-sectoral responses for adolescent girls and young women (AGYW). These investments include more than $78 million targeted to combination HIV prevention for AGYW. The focus on this population aligns with PEPFAR investments through the DREAMS program, thereby aiming for greater catalytic effect as well. In 2019, the program aims to reach 188,000 AGYW in 12 key districts with “a defined core package of services.” These also include life-skills training, PrEP for AGYW, self-testing for at-risk young men, and strengthening school management structures to better support HIV interventions (See GFO article from 27 Feb 2019). AGYW are a priority population for Global Fund grants in at least 13 sub-Saharan African countries.
As part of the 20-country Breaking Down Barriers human rights-focused initiative, in Tunisia the Global Fund’s financing for programs to reduce human rights-related barriers to HIV services has grown 200% from the previous allocation cycle. This funding supports baseline and ongoing assessments of human rights abuses and barriers to services, and effective strategies for addressing them in the Tunisian context, where the HIV epidemic is concentrated among key populations.
Person-centered systems for health
The CRG report states that while community engagement is generally recognized as integral to improving health outcomes, community systems and responses remain under-utilized. In recognizing, in its 2017-2022 Strategy, that resilient and sustainable systems for health (RSSH) underpin healthy and stable communities, in 2018 the Global Fund undertook several activities to expand its role as a thought leader in this area – in addition to funding RSSH programs.
These included workshops (at the Global Symposium on Health Systems Research in Liverpool, England, and a regional workshop in Cote d’Ivoire on community-based monitoring) as well as publications (an overview piece on the importance and dynamics of community responses to HIV, TB, and malaria, and ‘Focus On: The Crucial Role of Communities’, which provides basic guidance on the role of communities in RSSH).
The Global Fund is prioritizing community-based monitoring (CBM) – with the CRG department convening cross-departmental discussion within the Secretariat on how to further integrate it into Global Fund processes – because of its role in improving oversight, risk mitigation, and greater community ownership of Global Fund grants. The Technical Evaluation Reference Group has recommended that CBM be scaled up, and the Technical Review Panel has made recommendations on the inclusion of CBM in Global Fund grants.
Communities at the heart of Global Fund processes
The CRG report underscores the centrality to the Global Fund model of “empowering people most impacted by HIV, TB and malaria at every point in the grant, strategy, and replenishment cycles”. To this end, the Fund has several teams and programs in place to support the engagement of communities and people impacted by the diseases in its processes, including the CRG Department and the CRG Strategic Initiative, as well as the Civil Society and Political Advocacy Department and the CCM Evolution project, all working closely with the independent civil-society organization, the Global Fund Advocates Network (GFAN).
The report highlighted two regional activities that sought to put communities at the center of transition planning: a “learning and sharing forum” for Global Fund grant implementers in the Middle East and North Africa (MENA) organized by the CRG-SI Regional Platform host, International Treatment Preparedness Coalition-MENA; and a multi-component effort in Montenegro to strengthen key populations’ awareness of and engagement with transition planning.
In this ‘Communities’ section of the report, the CRG-Strategic Initiative is discussed at length, on the occasion of the mid-point of its implementation. The CRG-SI is a three-part initiative which supports six Regional Platforms for Coordination and Communication (see article in GFO 342), the provision of short-term technical assistance to implementers, and long-term capacity building for key population networks. (See Table 1 for CRG-SI outputs.)
Figure 1: Reach of CRG Strategic Initiative
Source: 41st Board Meeting – Community, Rights and Gender Report
|1: Demand-driven, community responsive short-term technical assistance||98 technical assistance assignments made since CRG-SI start (July 2017)|
|3: Regional Coordination and Communication Platforms||6 platforms supported communities in 98 countries to engage in Global Fund-related processes|
Looking inward: Managing risk and reinforcing internal capacities
In 2018, the Global Fund Secretariat took steps to strengthen and make more responsive some internal systems related to communities, human rights, and gender equity. The CRG Department, Grant Management Division, Policy Hub, Risk, Legal and Civil Society and Political Advocacy departments collaborated to develop guidance on “Managing Grants in a Human Rights Crisis.” The internal document, which sets out organizational protocols on managing situations internally and with partners, is expected to help the Fund navigate such crises more adroitly in the future.
Another approach to enhancing internal functioning for the benefit of grant performance is the ongoing work the CRG Department is doing to develop a CRG capacity-development strategy for the Secretariat itself. The point of this is to embed CRG expertise within grant management, to systematize CRG expertise, and to mobilize commitment to CRG across the Secretariat.
The report describes a range of various partnerships the Global Fund has been involved with over the past year, including community and civil-society partnerships, technical and bilateral partnerships, foundation and private-sector partnerships, among others. Many of these are long-standing.
We will not list exhaustively all partnerships here (see the report) but highlight the category of newer partnerships that reflect the CRG Department’s renewed focus on malaria, as well as cross-sectoral partnerships to advance TB and human rights. The report states that the RBM Partnership to End Malaria has become a key partner in three priority areas, as of September 2018. These are related to strengthening the advocacy capacity of community actors, the dynamics between malaria services and the most vulnerable populations, and promoting a person-centered approach to malaria programming as a pre-condition for UHC.
Finally, the report points to several efforts underway to strengthen reporting and data analysis capabilities in Global Fund grants. One approach involves the Fund working with countries to improve the collection of patient data, and to ensure that collected data is sex and age-disaggregated, to help future programming be better targeted and more responsive. One component of that is investments in Health Management Information Systems (HMIS) in key countries. The Fund has a target of 70% of the 51 High Impact and Core countries in its portfolio to have 80% of their respective health facilities using HMIS by 2020. By the end of 2018, 25% of the countries were using HMIS, which met that year’s target, according to the report.
The report also mentions the “rigorous M&E framework” being developed to capture the impact of scaling up programs to reduce human rights-related barriers in the 20 Breaking Down Barriers countries. The CRG team plans to share and apply the framework and the lessons learned beyond the 20 countries.
The report concludes with a reflection that much progress in the areas of community engagement, human rights, and gender equality has been made in the context of Global Fund programs and where it has grants. Nonetheless, it says, “much remains to be done. More attention is particularly needed to address gender-related barriers to effect responses across the three epidemics through into costs and funded programs, particularly for TB and malaria.”
In a separate statement to the GFO, made during the Board meeting, CRG Department Head Thomson said: “The Community, Rights and Gender Report to the Board is an important opportunity for the Global Fund Secretariat to provide an update on its progress in these areas on an annual basis. Given the cross-cutting nature of this work, it is always a challenge to capture everything in a short document. Responding to feedback received from a number of constituencies in previous years, we tried out a different structure this year – one that shares more examples of how the efforts of the Global Fund Secretariat, in collaboration with partners, are making a difference in countries for communities affected by the three diseases.
“We were also aware that much of the reporting on progress is now provided through Strategic Performance Reporting, so we kept information on KPI progress relatively short. Similarly, where we have been able to provide information via links or annexes, we have done so. We are keen to get feedback on the focus and level of information the Board would like to see in future reports and posed this question during the CRG session at the Board pre-meeting day, with further discussion anticipated with the Global Fund’s Strategy Committee. All suggestions welcome!”
As part of a decision made on Catalytic Investments (GF/B41/DP04), the Global Fund Board voted to continue to support the CRG Strategic Initiative, as one of 26 catalytic funding priorities defined for the 2020-2022 allocation period. The amount of funding the CRG-SI will receive will depend on which funding scenario (of five outlined in the Catalytic Investments decision) is achieved in the Sixth Replenishment.
- From GFO 354 (17 April 2019), article on a case study examining how the CRG-SI has advanced Global Fund objectives
- From GFO 342 (17 September 2018) article on the six regional platforms supporting the CRG-SI