I’ve been wanting to use this headline for a very long time. Some years ago the World Bank’s Global HIV/AIDS Programme published an operations manual, designed to help governments design and manage “multisectoral” AIDS programmes financed by World Bank grants or loans. The manual, which ran to several hundred pages, was called “Turning Bureaucrats into Warriors“. A pretty good title actually, emphasising the extraordinary efforts needed to effectively combat AIDS, and hanging on the public health industry’s penchant for militaristic terms (“attack rate“, “intervention“, “target“…). A call to arms.
Around the time Turning Bureaucrats into Warriors was published, I was involved in an advisory capacity – and a little later as a paid consultant – in the implementation of the “civil society” component of a large World Bank AIDS programme in one country. The primary approach was to provide small grants (around $500-$1000) to hundreds, even thousands of small community groups, to fund them to carry out short-term, small-scale, focussed actions primarily on HIV prevention. They could pick from a menu of five standardised activities, which included community awareness raising and advocacy with local leaders to speak out about AIDS. In terms of getting community groups to talk about AIDS for the first time I’d say it was a success, but several years on hardly any of us thinks short term awareness raising projects are of much value.
Moreover, the quality of what they did was often limited. I spoke to a number of grant recipients: they received little training to carry out their projects, often waited months for the first disbursement of cash, and sometimes never received the final “tranche” – the 10% they were entitled to on approval of their final report. The civil servants and NGO workers managing the programme, approving proposals, disbursing funds, and checking reports, were for their part often unimpressed with what community groups did. Reports wouldn’t get approved because they didn’t meet the exacting standards, according to which every last penny or cent had to be accounted for and documented with receipts. Even the half-litres of petrol from the informal market, even the bananas bought from street vendors to demonstrate condom use. (Previous readers may notice I’ve used the banana before. Apologies).
Community groups, many of which desperately wanted to do something, were being constrained in terms of what to do, how long to do it for, and forced to manage their finances as if they were standard players in the market economy. I couldn’t help feeling that what the programme was actually doing was turning warriors into bureaucrats. Some learned to play the game, others just gave it up altogether. What was particularly frustrating for me, was that as I worked on the initiative I discovered that the World Bank doesn’t require grantees or borrowers to apply this type of financial monitoring to community based projects. My suggestion to the government warriors running the programme that they adopt the Bank’s Community Driven Development approach, which drops the spreadsheets and instead encourages local groups to have their work appraised and monitored by the community they are serving – in other words the community signs off if it is happy that a decent job has been done – met with a stony silence.
Back to the present day
I’ve been thinking about this experience in the light of what is going on now at the Global Fund to fight AIDS, TB and Malaria. Just recently, Aidspan published an article that described the double standards the Global Fund operates when giving grants to different types of organisations. To cut a long story short, International NGOs who receive grants as “Principal Recipients” are allowed to charge an indirect “overhead” based on a percentage of the grant total. But national NGOs aren’t – they are expected to itemise and charge every single head office expenditure if they want the Global Fund to pay for it. Itemising and charging every single item is complicated and quite inefficient, and arguably, on the whole national NGOs have less capacity to do this than international ones.
Whatever happens, it is unlikely that the situation is going to change much for the organisations working under the Principal Recipients: the subrecipients, the sub-sub recipients, the sub-sub-subs… the local community groups. In other words the same types of organisations that were being funded through World Bank programmes a few years ago. These small, local organisations: the ones staffed by volunteers, with no computers and often little training, are still expected to account for everything. And it’s not just the bananas and the petrol. If community groups want funding to do outreach, you can be pretty sure they will be asked to get a list of the names, genders, national ID numbers and signatures of everyone they talk to as “proof” that they actually did the work. Think about what that means when, for instance, you are trying to build trust with stigmatised groups. Sign right here to confirm you’re a sex worker or homosexual please! What do you mean you’re a woman, your ID card says you’re a man!
It’s a topic I keep returning to but, if we’re really serious about the idea that community groups and organisations have a major role to play in things like health promotion, and health care, we need another approach. I suspect government-employed health workers, and local community health centres, aren’t expected to jump through the hoops that community groups have to in order to run their services. The World Bank’s “standardised activities” have been superseded by much better evidence of what works, and as I’ve argued before I think that it isn’t unreasonable to ask community groups to stick to certain norms and ethical guidelines when delivery services. That’s not bureaucracy, it is common sense, and moreover these guidelines can be designed in a way that allows groups to adapt them to their contexts. But we really need to move on from the bean-counting approach. We need to revisit some of the ideas from the World Bank’s community driven development model. We need to move toward some of the smart ideas coming up in the literature about involving communities themselves in monitoring, and using that mechanism as an incentive to improve services and to make sure money gets spent in a worthwhile way and to keep providers accountable locally, not just accountable to lists of names, activities, and folder-fulls of receipts. And we need to put in place mechanisms to ensure that community groups get stable, predictable funding, training, and advice, to help them meet the expectations of the people they are working for. In short, the question of whether NGOs getting grants from the Global Fund get overheads or not is relatively insignificant.
But I’m worried that donors’ growing apathy with HIV and civil society, and the Global Fund’s increasing risk aversion and attention to strict financial procedures, the emphasis on things that can be counted (and therefore described as “performance”) mean that things are about to get much harder for community groups. We shall see.