The Global Fund's Approach to Community Systems Strengthening Is Flawed
Editor's note: 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 (email@example.com) 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 (firstname.lastname@example.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.