A new report from the International Council of AIDS Service Organizations (ICASO) finds that Malawi’s Global Fund program improved in a number of ways during the 2017-2019 funding cycle. The total funding requested for key and vulnerable populations rose dramatically, and service packages for these groups were defined in greater detail. According to the report, a broad and systematic community engagement process contributed to these positive changes.
Yet, the title— “No such accountability is available on the ground”—draws attention to one of the report’s key conclusions: despite the many strengths of the funding request and its development process, there is a lack of community monitoring initiatives to ensure follow-through during grant implementation.
Aidspan has previously reported on Malawi’s 2017-2019 Global Fund funding request, as well as studies that show community engagement in Global Fund processes to be particularly effective there (see August 2015 GFO article).
The ICASO report covers five main dimensions of the 2017-2019 funding-request development process in Malawi: (1) The amount of funding requested for community-focused interventions, (2) the quality of program design, (3) the inclusion of community-articulated priorities, (4) perspectives from community representatives, and (5) a good-practice road map based on lessons learned. The report concludes with a series of recommendations for different stakeholders.
Increased funding for key and vulnerable populations in Malawi
In total, $10.28 million was requested for prevention programs among sex workers, men who have sex with men (MSM) and prisoners, in the 2017-2019 cycle, compared to $1.23 million in the 2014-2016 cycle (Figure 1). The amount of funding for adolescents and youth also increased dramatically. Malawi is among the 13 countries prioritized by the Global Fund for intensified investments in adolescent girls and young women (AGYW) (see January 2017 GFO article).
Figure 1. Comparison of total funding requested in Malawi’s 2014-2016 and 2017-2019 Global Fund funding requests (select modules)
For community systems strengthening (CSS), there was a significant decrease in requested funds. Key informants quoted in the report suggest that there was pressure from the CCM to focus on human resources and commodity security instead. This de-prioritization of CSS is linked to the report’s top-line finding that improved community monitoring is direly needed in Malawi.
At the 39th Global Fund Board Meeting in May 2018, a strategy implementation update highlighted the limited CSS funding in grants. Money for CSS constitutes just 5% of approved funding for building resilient and sustainable systems for health (RSSH). The update says the Global Fund is pursuing ongoing internal engagement to build consensus on the value add of community-based monitoring and feedback mechanisms.
More comprehensive service packages
Along with increased funding for key and vulnerable populations in the 2017-2019 cycle, there are also clear improvements in program quality in Malawi. The report includes a comparative table with the specific language in the 2014-2016 and the 2017-2019 funding requests for key community-focused modules.
The reach targets for sex workers and MSM significantly increased to scale up access to services. The grant aims to cover 6000 sex workers and 3600 MSM with a comprehensive package, compared to 2000 and 1350 in the last cycle, respectively. These key populations programs expressly move from partial service packages to comprehensive ones, as well as from fragmented delivery to a one-stop-shop approach.
For AGYW, the 2017-2019 funding request explicitly mentions a focus on quality over quantity, reducing the reach targets to expand and improve the depth and breadth of the package of services offered. Structural elements are introduced for AGYW, including activities to address gender-based violence, keep girls in school, and strengthen economic opportunities.
The report raises a concern that, unlike the other modules, the community responses and systems module (formerly called CSS) is lacking in specificity and missing key human rights and gender considerations.
Inclusion of community priorities in the funding request
Community priority-setting and advocacy efforts are linked to the improvements in requested funding and program quality for key modules. With support from ICASO, a broad consultative country dialogue process was led by the Malawi Network of AIDS Service Organizations (MANASO) and by the vice-chair of the Country Coordinating Mechanism (CCM), who represents civil society. A set of community priorities were documented during this process.
Of the 26 priorities set by communities during country dialogue, 16 were either fully or partially included in the final submission to the Global Fund (Table 1). Many priorities related to key and vulnerable populations were included. However, priorities related to monitoring treatment stockouts, developing community scorecards, conducting community oversight and feeding back monitoring information to communities were not fully taken on board.
|Community Priority||Level of Inclusion in Funding Request|
|Increased condom education and distribution||Partially Included|
|Reduce HIV incidence among AGYW through both testing and treatment of potential sexual partners (men 15-40) and primary prevention||Included|
|Creating an enabling work environment for sex workers (safety & security)||Not Included|
|HIV treatment adherence support for female sex workers (FSW)||Not Included|
|Access to HIV treatment for men who have sex with men||Included|
|Services for prison populations, including condom provision in prisons||Partially Included|
|Services for marginalized populations, including women and people with disabilities||Partially Included|
|Stigma reduction among people living with HIV||Not Included|
|Training of health workers in key population and human rights||Not Included|
|Reaching key populations with HIV testing||Included|
|Scale up HIV testing services in rural areas||Not Included|
|Community-based HIV testing services||Not Included|
|Male engagement to increase HIV testing among men||Included|
|Placement of CD4 equipment in rural health facilities||Not Included|
|Monitoring viral load suppression||Partially Included|
|Increased diagnostic technology for TB to reduce diagnosis time||Included|
|Test-and-start should be rolled out, together with TB screening||Partially Included|
|Increase the number of community health workers||Partially Included|
|Community and health center linkage, in order to increase referrals||Included|
|Involvement of community-based organizations in service delivery||Partially Included|
|Orienting community-based organizations (CBOs) in demand creation for HIV testing||Not Included|
|Reporting to communities and beneficiaries on grant progress||Not Included|
|Harmonization of interventions on community oversight of health facilities||Not Included|
|Coordination meetings at the district and national level||Partially Included|
|Evidence-based advocacy with community data scorecards||Partially Included|
|Monitoring of stock outs and malpractices||Partially Included|
A more inclusive country dialogue, gaps in grant monitoring
To help explain the abovementioned successes and challenges, the report shares perspectives from 13 key informant interviews.
Informants link the improvements to Malawi’s Global Fund program with a concrete priority-setting process, led by MANASO and civil society CCM representatives, and conducted through a wide and inclusive country dialogue. According to a key informant from a civil-society umbrella body:
“Now [in 2017], we were able to go beyond Lilongwe. We were able to go subnational. The people on the ground—those that are at CBO [community-based organization] level—had their voices added to the table in the new grant. We were also able to expand the constituencies. We included the key populations, FSW, MSM, prisoners, women and young people. In the other round [in 2015], this was not comprehensive and now we were able to get the input of these groups to the table, which does really matter [for what gets included in the grant].”
However, significant gaps remain. A key informant from the National AIDS Commission flags the need for increased civil society capacity and community monitoring support:
“Due to the lack of capacity on the part of the CSOs [civil society organizations] to check the accountability of the PRs, SRs [sub-recipients] and SSRs [sub-sub-recipients]—if they are properly implementing on the ground—the transparency and accountability is also very weak. Since it is weak, no such accountability is available on the ground.”
The report’s emphasis on the need for improved community monitoring coincides with a November 2018 statement from Malawi’s National Civil Society Consultative Forum for Global Fund. In that statement, 19 undersigned civil society organizations call for increased scrutiny over how Global Fund resources are being utilized in Malawi. Recent reports from the Office of the Inspector General raised similar accountability concerns (see January 2017 GFO story on OIG 2017 audit and August 2017 GFO story on OIG investigation into drug thefts).
Another shared theme in the ICASO report and the Consultative Forum statement is the need for sub-granting flexibilities so that more local CBOs are able to access Global Fund resources.
Ways to improve accountability
Based on lessons learned, the ICASO report concludes by urging communities in Malawi to stay engaged throughout the funding cycle, especially during grant implementation. Recommendations are targeted at civil society, technical partners, CCM members, and the Global Fund Secretariat.
The report calls for partners to invest in strengthening the monitoring, evaluation, oversight, and knowledge management mechanisms of MANASO, as the key coordinating body for CSOs. The authors suggest that CCM members identify innovative ways of providing feedback to their constituencies, including electronic-based systems. The report is also forward looking, recommending that the Global Fund ensures enough time between the issuance of allocation letters and submission windows, so that rigorous and meaningful community engagement can take place in the development of the request. The release of the allocation letters for the 2020-2022 funding cycle is anticipated towards the end of 2019.
Gemma Oberth and Emma Gausi are the co-authors of the ICASO report. Gemma is a policy advisor for ICASO, based in Cape Town, South Africa. Emma is a Lilongwe-based independent consultant.
Disclosure: Gemma also consults directly with the Global Fund, supporting the Community, Rights and Gender Strategic Initiative. This was declared to Aidspan and was not considered a conflict of interest in light of the authors’ unpaid contribution to the GFO in order to share the report’s findings.