Tool developed by Global Fund and APMG Health used in transitioning countries to assess sustainability of services for key populations
As more and more countries in Latin America and the Caribbean (LAC) become ineligible for funding from the Global Fund, there have been legitimate concerns about the sustainability of the response to the diseases in these countries – in particular, whether civil society organizations (CSOs) will be able to continue to play the vital role of providing prevention, treatment and care services for key and vulnerable populations. With an increasingly greater share of funding for the response coming from implementing governments, there is a risk that they will not step in to fund and support civil society programs that are currently funded by external donors.
To address these concerns, the Global Fund and APMG Health, a social benefit corporation that works to improve the health and well-being of marginalized populations, have developed a Diagnostic Tool on Public Financing of CSOs for Health Service Delivery, also called the “social contracting diagnostic tool (SCDT).” The tool is used during transition planning in countries that are expecting significant reductions to external financing and where this financing is currently being funneled to CSOs to support the response to the diseases.
The tool is used to assess whether CSOs can use government resources to continue to provide services for populations most affected by the diseases. It poses a series of questions to help identify and address barriers and opportunities to reaching key populations using public sector funding. It guides a country in examining whether (a) CSOs are legally allowed to register in the country; (b) provisions exist to enable registered organizations to receive funds from the government; (c) registered CSOs use those government funds to address the epidemics among key populations; and (d) CSOs are meaningfully engaged in planning and implementing the response. This is important because even if a country legally allows CSOs to register and be funded by government budgets, there may be limitations regarding the populations they can work with or the types of interventions they are allowed to carry out.
The tool suggests using a combination of desk review and in-country interviews with key stakeholders such as country coordinating mechanisms, CSOs, legal and procurement experts, government and international organizations to answer a series of descriptive and yes or no questions. The data collected in this phase is then used to develop an analysis to help prioritize next steps.
The analysis section of the tool aims to get countries to provide answers to the following four overarching questions:
- What is going well in terms of government funding of CSOs? What precedents are in place for social contracting or similar mechanisms? What are the possibilities for replication or scale-up?
- What specific barriers have been found to full and effective implementation of social contracting (legal, structural, political will, technical, capacity, and financial and human resources)?
- What recommendations can be made to improve social contracting?
- What activities will be required to implement the recommended changes? How should those activities be prioritized? How will progress be monitored and evaluated?
The tool has been piloted in different ways in a number of countries in LAC. In Panama, Paraguay and the Dominican Republic, the tool was used as part of transition readiness assessments (TRAs) to fill in the section on CSO readiness to transition, and the analysis was included as an appendix to the TRA reports. In Guyana, the tool was used for a stand-alone exercise in assessing possibilities for public financing of CSOs. Some of the key findings from the use of the tool in these countries are summarized below:
Panama’s analysis of social contracting (the TRA is available here) found that there are no legal barriers to social contracting and there is theoretically a legal framework which allows CSOs that work on HIV and TB to be funded by the government. However, there are structural barriers, likely on account of conservatism and homophobia, that delay the registration of organizations working with men who have sex with men, transgender people and sex workers. In addition, technical capacity within the Ministry of Health (MINSA) is limited in regard to public tendering for the provision of services for HIV and TB, and there has been no inclusion of CSOs in the national budget.
The analysis recommended that technical assistance (TA) be provided for both the HIV and TB programs to develop and implement a social contracting mechanism that builds on the experience of other ministries in Panama and the experience of other countries. The analysis identified a need to build technical capacity within MINSA; and within CSOs to strengthen their capacity to obtain, implement and monitor contracts from the government. Some TA will be needed to build CSO capacity to carry out joint advocacy to ensure robust civil society participation in the process. The analysis also recognized the need to work on stigma and discrimination in order to reduce barriers faced by key populations; and to develop national technical guides in accordance with international recommendations (e.g. prevention, voluntary counselling and testing) as these guides do not currently exist.
According to the Dominican Republic’s analysis (see TRA), there is currently legislation that grants government funding to non-profit, non-governmental organizations to provide services. However, it was developed nine years ago, needs updating and has not been adequately implemented – although the current government is demonstrating the will to do so. The National Center for Development and Promotion of Non-Profit Associations, which is attached to the Ministry of Economy, Planning and Development, has previous social contracting experience awarding government funds to CSOs. However, CSOs report challenges in securing the required paperwork to be registered by the center, and thus have difficulty complying with current legislation and participating in public calls. Moreover, as was the case in Panama, there have been no budget allocations from the Ministry of Public Health to fund CSOs responding to the needs of key populations.
The analysis suggested that the center will require support to work with the Ministry of Health to streamline the latter’s bureaucratic procedures and establish a better mechanism to register CSOs. Also, the center’s staff will require further training to develop public calls and oversee contracts for HIV and TB programs to make up for their lack in capacity to do social contracting. For their part, CSOs will also require some training or mentorship, both on project management, so they can effectively implement programming, and on advocacy, to shore up political commitment and ensure consistent budget allocations. The analysis recommended that a pilot project of public calls be rolled out and refined.
At the time of writing, Paraguay had not decided to make its TRA report public.
Guyana conducted its analysis as a standalone exercise and, therefore, was able to achieve a deeper contextual analysis. In Guyana, CSOs have the legal right to register and receive funding from the government, and there are no limits concerning working with key population groups. However, CSOs complain of unreasonable delays or outright denial of registration, likely on account of stigma and discrimination. Subsidies are routinely provided to CSOs, although the process is not entirely transparent or de-politicized – and no HIV organizations and only one TB organization have received funding in 2016. There are no regulatory restrictions on activities that CSOs can carry out. However, for service delivery, the CSOs must be trained and licensed, and must respond to government priorities for HIV and TB, in line with strategic plans. While strategic plans exist for both HIV and TB, they have not been costed, and CSOs have not been included in budget allocations.
The analysis recommended that the scope of work for CSO engagement be further defined by costing the plans and setting a budget and targets for CSO activities. It also suggested developing and piloting a social contracting mechanism that is open and transparent. The report recommended bringing together multiple stakeholders to develop a mechanism for planning, procurement, implementation and accounting of CSO contracting for HIV-related services and programs. Both CSOs and the government will require subsequent training to implement and monitor the model and ensure adequate programmatic and financial reporting. The report also said that new legislation could help alleviate bottlenecks related to CSO incorporation.
It is interesting to note that despite the varying contexts, the different assessments raise similar issues and provide many of the same broad recommendations. It is also worth highlighting that the tool has some important limitations: It does not focus on the ability of CSOs to conduct advocacy on behalf of key populations with the government, nor does it look at the sustainability of community health programs that are currently funded by the government through hospitals or health agencies. While the latter issue may be less contentious – as the expectation may be that these programs (e.g. community health workers) would simply continue uninterrupted post transition – it may not be entirely realistic to expect the government to readily fund organizations or projects whose express objective is to hold their feet to the fire, particularly with respect to key populations.
Aidspan plans to continue to cover topics related to sustainability and transition in GFO.