My first proper blog post was about the big new idea of community systems strengthening, which the Global Fund to fight AIDS, Tuberculosis and Malaria is hoping to provide significant support to during its tenth funding round. The Global Fund, as well as UNAIDS, have developed documents and tools to help countries writing proposals to the Global Fund to use this new concept.
The idea is to ensure that civil society or community based organisations receive sufficient funding and “capacity building” to be an effective part of efforts to fight AIDS, tuberculosis and malaria. Civil society organisations have always been some of the most creative, active, and activist organisations working to fight these diseases and the various injustices that surround them, both by demanding that governments and health sectors take action, and by delivering services themselves when governments and health sectors can’t or won’t. Community activism is one of the main reasons the Global Fund was created in the first place.
The idea of “community systems” for health – and human rights – is incredibly exciting, because it is clear that governments in most countries can’t meet health care needs on their own. The idea of community involvement in health and of working in communities before people fall ill isn’t new, but in many countries it is still just an idea, or even an ideal. Some civil society groups can also play a role in identifying and tackling marginalisation and human rights violations that make people more vulnerable.
The international community – again largely on the insistence of civil society groups – has set ambitious targets for addressing some of the world’s most pressing health problems. One of these targets is that there should be universal access to HIV prevention and treatment services for people who need them by 2015. That means not only providing a lot more services, but it also means getting rid of the barriers that stand in the way of people getting these services or being able to protect themselves.
Is “community systems strengthening” going to get us there? In my view, it depends how it’s done. It also requires a big shift in how not only governments, but also civil society organisations work. This note focuses specifically on the challenges related to service delivery by civil society organisations.
In my previous post I hinted that I think that for the community systems concept to work, we need to start thinking about what does and doesn’t work in formal health systems. The strong points can help us define how best to structure civil society organisations. The weaknesses can help us define what roles civil society organisations can play. In other words, if we’re serious about using the word “system” to talk about what civil society organisations do, then we need to think in a more systematic way. Specifically this means civil society organisations need to move away from reasoning in terms of what they can do or what they want to do, towards thinking in terms of what all actors (from both civil society and the formal health sector) need to do collectively to respond to needs. Systems-approaches need to be introduced at different levels:
In order to know what collectively the different actors need to do, there needs to be a good, common understanding of what the needs are. Although this is problematic in many settings, there has been a lot of progress in recent years, in particular in terms of identifying the groups that are most affected by the epidemic and the best ways of providing HIV treatment. Although the concept of priority groups and interventions has gained traction recently, priority doesn’t always mean priority: decision-makers may be happy to fund programmes with priority groups but are often reluctant to turn down funding for others. This is a problem when not all members of priority groups are being reached.
Secondly there needs to be a good, common understanding of what types of service or action should be provided to respond to each set of needs. At the moment the exact content, quality and cost of services provided – particularly by civil society organisations – is highly variable. This makes it nearly impossible to carry out rational planning. And yet we’ve also come a long way in terms of identifying the types of services that are needed in different contexts. To be sure there will always need to be some variation, and “contextualisation” of services, but this should be based on broadly accepted, evidence-based standards – not based solely on the capacities or organisational biases of whichever NGO happens to be working in a given location or with a given population. We also know that no single intervention is sufficient to make the difference needed, and that few if any service provision organisations are able to provide all of the services or interventions that make up a comprehensive package. What this means is that no one organisation can be expected to have an impact by working alone, and therefore partnerships between organisations are essential.
What this means is, that at national level it is necessary to put in place joint planning, based on a joint, evidence-based assessment of needs and jointly accepted standards for services to be delivered. Civil society organisations are a diverse group with diverse interests and skills, and priorities. Some organisations may be focussed on issues or services that are not, on the basis of the evidence, priorities for the AIDS response. For this national level work to be useful it is necessary to have strong, functioning networking of civil society organisations, and for these organisations to be represented by leaders who have a combination of the technical skills and understanding of evidence required to participate effectively, excellent knowledge of the concerns of community groups, and the credibility and leadership required to obtain buy-in from civil society organisations, in particular for decisions that are unpopular.
It is also necessary to urgently develop clearer definitions and standards of the types of service and interventions that civil society organisations can provide – at country level. The World Health Organisation recently published a guide on HIV interventions in the health sector. We need something similar for civil society organisations. Or perhaps more ambitiously, we need something similar which captures all services and interventions, irrespective of whether they are health sector or community based, and that countries can adapt to their context. The aim should not be to restrict programming or creativity, but rather to insure that any service provider – whatever their sector – is adhering to evidence based approaches while allowing them the flexibility to adapt these norms in their own programmes. This will also help to shift thinking back to a “community focused” approach, based primarily on responding to the needs of communities and ensuring they have access to services, rather than being based primarily on what each provider is willing or able to do.
The principles and priorities established at a strategic level need to be made operational. Assuming that the strategy has identified sites for the different priority community groups, and assuming that the focus is to respond to the needs of each community, it is necessary to bring together all of the actors in a given location – as well as representatives of the relevant communities – to identify what is already in place, to identify gaps and overlaps, and to decide how best to fill the gaps and reduce overlaps. Resources should be provided to enable actors to work in a continuous way – this is particularly important for civil society organisation programmes, since community interventions are often designed (or funded) to be short-term. Evaluations shouldn’t be focussed on how many people received services, but what proportion had access to services and what the changes were as a result. Results of evaluations should reflect the collective responsibility of all actors, rather than individual actors being expected to demonstrate an impact that they are unlikely to have made.
Funding and technical support level
Funding and technical support do not come last, chronologically speaking – but they are means to an end, and they only make sense once there is clarity on what needs to be achieved. Whenever I am thinking of a “community systems” problem, I ask myself if there is a parallel in health systems, and if the health systems way of thinking can help in diagnosing the problem and finding the solution. Health centres don’t get funded for just a 6 month period: NGOs often do. Health centres aren’t supposed to get interruptions to their funding – although it happens quite often. But it happens all the time to NGOs, in fact it is structurally part of how funding to NGOs is allocated, since they can rarely get a new funding tranche without submitting a progress report. And this means NGOs spend a lot of time filling in monitoring and accounting forms rather than worrying about the impact of what they are doing.
Another example is that health centre interventions are always seen as being continuous, in principle; NGO ones are often seen as being “one-off”. This is a particular problem for NGO programmes on HIV prevention, because somehow, decision-makers still seem to think that prevention means telling people about HIV then shutting up shop.
Technical support is much the same. People who staff health centres are normally highly trained before they start, and receive in-service training too. For NGOs it’s luck of the draw… it depends whether the donor is convinced it is worthwhile spending the extra money. Working to improve the quality of what NGOs do, by improving funding and technical support conditions, seems to be something of a luxury – maybe because health sector decision-makers still don’t think NGOs have that much to offer. Whatever the reason, if we’re serious about community systems, there needs to be a fundamental shift in the ways in which community actors are supported to do their work.
Hope this isn’t too negative but…
I’ve spoken to quite a few civil society and national AIDS programme people about this over the past few years. A lot of them don’t agree. Some say that communities / CSOs are inherently “systems”, but that some are weak and we have to help strengthen them. I personally don’t think that it is possible to generalise, especially when talking about marginalised groups and the extent to which they are excluded from the mainstream “community”. I also worry that this approach doesn’t do justice to the types of input and support that are needed to improve health.
Many people from civil society organisations that I speak to seem worried that a more systematic approach will destroy their creativity and flexibility; that it will compromise their independence, and their ability to work with communities to identify needs and the best ways of responding to them. National AIDS programme people – and people from formal health sectors – worry about sending the message that the government needs help and about being seen by NGOs and international partners as wanting to control civil society action. They also frequently express concerns about civil society organisations’ capacity to deliver effective services. There is some legitimacy to the concerns on both sides, although it is important that they don’t just become lazy assumptions that justify inertia. But through my recent work helping to plan national AIDS programmes, I’m starting to wonder whether the assumptions have taken control. If we’re going to succeed, we need these walls to come down and to have more leadership and openness on all sides.
PS – Anyone from the Global Fund reading?
What I am saying here is relevant to the ways in which the Global Fund allocates funding – in particular the requirement for countries to issue bottom-up calls for proposals, since this makes it almost impossible to design and stick to an overall strategy for the national proposal. Very often, the proposals that come from NGOs don’t collectively meet the epidemiological priorities of a country. So, either the wrong projects get funded or a lot of organisations end up being turned down.
It would better serve the interests of NGOs and, more importantly, of affected communities, if countries could get funding for an overall strategic approach, and then allocate funding and technical support to the right organisations working on the right sort of projects. Just saying.