Category Archives: Civil Society

Country Ownership and Global Fund Grants

The latest edition of Global Fund Observer (#218) from AIDSPAN raised a lingering question about the Funds founding principles – what is country ownership and how is it practiced? The thoughts range from the more altruistic – let the country decide what it needs to do and we’ll give the money – to the more crude, though not stated as such – give the country enough rope (money) to hang itself.

Another founding principle involved the Global Fund seeing itself as only a financial mechanism, not a technical one like the World Health Organization or UNICEF.  AIDSPAN demonstrates how over time, while still not providing direct technical assistance, decisions from the Technical Review Panel and the Global Fund Board, among others, can be seen clearly as offering a technical guidance that must be heeded if funds are to flow.

In short AIDSPAN has shown how the Global Fund itself has taken a more directive role, though often based on programmatic evidence and advocacy from those who have a stake or experience. We also need to look at th other side of the coin – within the country, who owns the Global Fund process?

A major overhaul of Country Coordinating Mechanisms (CCMs) some years ago was stimulated by the realization that government agencies are not the sole representatives of their countries and peoples.  While civil society and non-governmental organizations were expected to play a role in CCMs, they were often ignored and rarely had major roles in deciding on and implementing Global Fund sponsored programs in their countries.  Sometimes the advocacy mentioned by AIDSPAN was prompted by CSOs and NGOs not being heard within their own countries.

AIDSPAN mentions changes that the Global Fund has strongly suggested such as having dual track principle recipients (PRs) representing government and the non-governmental sectors.  While this may have represented a somewhat heavy hand from Geneva, the results sometimes reflected the status quo ante and NGO PRs were often relegated to less well funded aspects of programming such as behavior and social change.

Global Fund recipient countries represent a wide diversity of political systems in various stages of evolution.  It would be naive to expect that country ownership really embodies democratic participation of all stakeholders, public, private and NGO, in decision making and implementing on an equal footing – and no one really believes that is fully possible in at present.  Still it is a long term goal and a principle that should guide funding decisions as much as the quality of the technical content of proposed activities.

alma-q1_2013_-_english_scorecard_sm.jpg

In the meantime we can look for additional ways and means to hold countries accountable for their health and social programming decisions. A good example is peer influence from the African Leaders Malaria Alliance (ALMA) which regularly publishes a scorecard of progress toward key health indicators. This freely available score card shows for example, in the first quarter on 2013 only six countries meeting the criteria of good financial management set by the World Bank. In the countdown to 2015, only eight countries are on track in terms of breastfeeding coverage.

As AIDSPAN observes, “But one has to acknowledge that, in the process, the concept of ‘country ownership’ is certainly evolving. Perhaps it will evolve further under the new funding model.” We hope the concept evolves along lines of full and equal partnership among all stakeholders within a country – that all sectors and peoples within a country will truly ‘own’ and thus influence the decision and actions around programs supported through the Global Fund.

Have we reached a funding plateau for malaria?

As all eyes are on the Global Fund to Fight AIDS, TB and Malaria with its launching of the new funding mechanism in February 2013, but we have been cautioned to curb our enthusiasm.

Karanja Kinyanjui in Aidspan’s Global Fund Observer explained that “While funding for all health sub-sectors grew over the 2002 to 2010 period, funding for HIV/AIDS, malaria, and TB increased at faster rates than other sub-sectors such as family planning, nutrition, workforce/management and other infectious diseases,” the growth spurt has leveled off. Readers were asked to see the new Kaiser Family Foundation report on the funding situation.

For malaria we are likely to be plateauing at levels that are only half of what is needed annually to move countries into the pre-elimination phase. The Kaiser Report specifically concludes that …

“While health grew as a share of overall ODA between 2002 and 2010, reflecting its priority among donors, year-to-year increases peaked in 2007 and have declined in each subsequent year. Combined with the OECD’s announcement that ODA in 2011 declined in real terms after more than a decade of steady increases and preliminary estimates that ODA (overseas development aid) is not expected to increase significantly in the coming years, caution about future donor assistance for health may be warranted”

kaiser-oda-for-health-2002-10-sm.jpgODA Health funding did grow from $4.4 billion to $18.4 billion between 2002 and 2010. Even under this increase, malaria funding did not meet needs. Malaria was a negligible component in 2002, and reached $1.6 billion, but this along with aid for nutrition, reproductive health, basic health services and others was dwarfed by HIV/AIDS funding at $7.4 billion for 2010.

In the past two years since the Global Fund Round 11 was cancelled there has been “a significant impact on programmes to fight AIDS, TB and malaria including, in particular, programmes being implemented by civil society organisations (CSOs). Programme scale-up and even some essential life-saving interventions that were planned by countries were halted.”  The transitional funding mechanism allowed some countries to tread water, but the new start up in February will not hit the ground with funds for at least a year.

Other aid sources such as bilateral programs in the UK, USA and Germany and multilaterals like the World Bank and UNICEF are certainly key players in malaria program financial support, but their help can supplement the big source, Global Fund, not replace it. Bilateral programs in particular are hit by budget problems that yield at best no increase in ODA, if not cuts.

The Eurasian Harm Reduction Network describes the current funding situation succinctly – “Quitting while not ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction …” The situation with CSOs shows their dependence on large donors, too – so we cannot find our way out by simply donating to charity no matter how many NGOs assure us our individual dollars will give someone a bednet.  Malaria elimination is a problem that requires going to scale by the whole global community.

Fate of Civil Society at the Global Fund

The Global Fund Observer has poignantly highlighted the risks of losing a voice for civil society at the Global Fund.  The Fund to date had been one of the few donor groups to actively encourage civil society organization (CSO) participation on grant writing and management and has developed the innovative community systems strengthening approach to show that the people who live with the conditions supported by grants are as important as the systems that deliver formal health services.

kenaam-2.jpgWhile civil society is not perfect, it has served important functions within the Global Fund strategy.  To date the Global Fund Board has asserted the need for civil society representation on Country Coordinating Mechanisms (CCMS) as well as ensuring that CSOs are also considered equally as principal recipients (PRs) of funding.  This was based in part on findings some years ago that CSOs achieved better grant performance scores on average than did government or UN agency PRs.

CSOs come in many colors, but an important function of CSOs in any setting, even beyond the funding and management of Global Fund projects, is to serve as advocate and watchdog.   This is a crucial role as the GFATM’s Office of the Inspector General continues to uncover problems in grant management.  Here we don’t want to confuse NGO with CSO because some politically well connected NGOs have been caught with their hands in the till just as have government ministries. (One even wonders if recently disclosed Global Fund improprieties in Mali’s Ministry of Health were not a symptom of government weakness and corruption that led to its downfall?)

There is even worry expressed by the Civil Society Action Team that these moves might threaten the role of civil society in CCMs.
After dissolving the Civil Society Team at the GFATM, the new management wants civil society to feel happy that they now have several paths through which to pursue their interests – thus is laughable – the more paths, the more confusion and the less clear the status of civil society.

As mentioned from the start, the GFATM pioneered civil society involvement in major international grants processes because the ultimate recipients of such grants are often ignored with the consequence that targets are not achieved.  Most of the money that the GFATM receives comes from individual taxpayers in G8 countries. We taxpayers as members of our own communities want equal recognition of the members of endemic country communities in providing oversight to grants and becoming active participants in program implementation and evaluation.

It is not too much to ask that the people who should benefit most from the Global Fund have a distinct, definable role in the Fund’s processes.

Community Transportation System to Save Maternal Lives

dscn2401sm.jpgGuest contribution from: Ahmed Mohammed Ahmed, Community Mobilization Specialist, Targeted States High Impact Project (TSHIP), Bauchi State, Nigeria

TSHIP aims to improve maternal and child health in Nigeria by strengthening health services and enhancing community participation. An example of the latter follows:

Five Ward Development Committees [WDCs] in Pali and Kungibar Districts of Alkaleri Local Government Area in  Bauchi State have initiated a community approach to emergency transportation for pregnant women and children.  This is at the background to recent 2OO8 NDHS survey which showed high rates of maternal and child mortalities in the North-East part of Nigeria.

dscn2450sm.jpgThe initiative which saw a strong commitment on the parts of different community and ward structures like the National Union of Road Transport Workers [NURTW], Okada Riders Association (motorcycle taxi drivers), Health Providers, Traditional and Religious leaders, was witnessed by other stakeholders such as Alkaleri LGA whose Chairman was represented at the occasion by the Director PHC.

The event was marked with a short drama presentation (see at right) highlighting the objective of the Emergency Transport Team [ETT], which is to provide free transport service to pregnant women and children under 5 from all the communities within the five wards.  Mobile phone numbers of the executive committee members and that of other drivers and motorcycle drivers in the scheme were provided at the inauguration for ease of contact. (see transportation committee members at left)

dscn2443sm.jpgIn his brief speech at the occasion, the visiting Chairman of Bara WDC in Kirfi, Malam Haruna Katukan Bara, says ‘I am here to learn about this unique experience and also help my ward in replicating it.’ He also urge community members to support the good works of the WDCs towards the development of humanity.

Finally, one of the community’s traditional birth attendants (right) thanked the committee for taking action to save the lives of pregnant women in the wards.

China – an odd position with the Global Fund

China has recently made the news because grants from the Global Fund have been frozen over non-adherence to GFATM procedures. As reported on Yahoo Health News a spokesperson for the Global Fund said, “We believe that the main recipient, the CDC (China Centers for Disease Control), had violated an accord of the Global Fund which said that a part of the financing accorded, at least 35 percent, must go through community organisations.” As Yanzhong Huang explained, “The (Chinese) government may like the Global Fund money, but it obviously does not like the Global Fund’s ideas as far as civil society is concerned.”

To date, China has been awarded 14 GFATM grants covering all three diseases. Generally the grants have performed well. These grants have a lifetime budget of nearly $2 billion of which nearly $1 billion has been approved.

Let us compare this scenario against the world economic picture. Last August the New York Times reported that, “After three decades of spectacular growth, China passed Japan in the second quarter to become the world’s second-largest economy behind the United States, according to government figures released early Monday.”

To date China has pledged $30 million to the GFATM, and paid $20 million. China is not the only recipient country to contribute. Even Nigeria, whose economy is nowhere near as large as China’s has pledged $29 million and paid $19 million. Other recipients who have provided some support range from Malaysia to Rwanda.

In the end when one looks at a $30 million pledge compared to $2 billion worth of gain by the second largest economy in the world, one wonders why China does not or can not shift over to the donor side of the equation completely.

The thoughts of Yanzhong Huang on how to deal with this situation might be construed as appeasement. “In order to encourage the participation of China’s civil society groups in global health, it is important to allay the fears of Chinese leaders.” A harsher approach might be to say that if China no longer received GFATM money, there may be no need to allay fears. As the world economy slows, more of the G20 countries need to think seriously about how they can step up to the donor table and behave as if it were better to give than receive.

Faith Based Malaria Campaign

fuh_logo.JPGWhen the words ‘religion’ and ‘Nigeria’ appear in the same sentence the implications can be mixed. Religion certainly plays a big part in Nigerian society. “A survey of people’s religious beliefs carried out in 10 countries (in 2004) suggests that Nigeria is the most religious nation in the world,” according to the BBC. Over 90% of Nigerians said they attended a religious service regularly, more than any of the 10 countries surveyed.

The survey also found that, “More than 90% of those surveyed in Nigeria and Indonesia said they would give their lives for their beliefs.”  This presents the other side of religion in the country.  Over the years the BBC has reported that religion is one of the major flashpoints for conflict in Nigeria. Religion continues to challenge the social and cultural fabric of the country. The difficulty in distinguishing religious, economic and ethnic sources of conflict has seemingly made the challenges more intractable.

Along comes a ray of hope, spurred by of all things, a deadly disease like malaria. The Center for Interfaith Action (CIFA) described Faiths United for Health (FUH) and reports that …

The Sultan of Sokoto and the Archbishop of Abuja, along with other leaders of Nigeria’s Muslim and Christian faiths, today joined Nigerian government officials to launch an unprecedented effort to eliminate deaths from malaria throughout the country. By the end of 2010, the religious leaders plan to train 300,000 imams, priests, pastors, and ministers to carry the malaria prevention message to cities, towns, and rural villages through sermons and other cooperative efforts.

The Christian Post quotes U.N. Secretary-General’s Special Envoy for Malaria, Ray Chambers, who attended the launch of the Nigerian Inter-Faith Action Association’s campaign in Abuja as saying, “Working together, Nigeria’s faith leaders have the credibility, influence, and reach to carry the message that ‘bed nets save lives’ to their nation’s most distant villages.”

The implication is that the more than 60 million insecticide-treated bednets being distributed in 2009-10 will only be effective if they are accepted, hung up and slept under. With such a large portion of the population attending religious services, the potential for an interfaith push to actually use the nets should have a big impact on reducing the disease. As John Bridgeland has said, “Faith-based and other leaders in civil society throughout Africa are emerging from the grassroots to ensure that nets are used properly in homes and villagers know the warning signs of malaria so they get help in a timely fashion.”

ogun-1a.jpgWhile the FUH offers hope, two important issues remain to be addressed.  First, malaria cannot be controlled in isolation and simply through campaigns. Efforts require a strong primary health system to sustain malaria control. Unfortunately This Day highlights, “Part of the irony of our national development is that rather than situations improving, some key sectors tend to deteriorate. One such instance is in the health sector where the once robust primary health care system is almost completely extinct now.”

Secondly, perceptions of malaria illness are culturally based. It is not clear how indigenous African beliefs and religion fit into FUH.

Nigerians, like most people around the world, do not abandon their cultural beliefs just because they practice a cosmopolitan faith. Without attention to the indigenous cultural core of a peoples (e.g. sacrifice of beans and palm wine to Ogun at left above), we may risk low acceptance of our ‘miraculous’ malaria interventions.

An integrated approach to HIV, TB and Malaria through FBOs

The Council of Anglican Provinces of Africa (CAPA) has a strategic 5-year plan for integrating its work on HIV/AIDS, TB and Malaria. Some aspects for the rationale for an integrated approach include the following:

  • Control of all three diseases is affected by the same overall quality of care issues including infrastructural and human resource needs
  • Faith based organizations have the ability to reach communities and individuals impoverished and affected by all three diseases through their health services and parish programs
  • Pastoral care does not distinguish people by the diseases they have, but sees them as whole persons

Specifically for the Anglican community, CAPA explained that, “The Church is uniquely positioned with the ability to reach out to communities through her organized network and constituencies. CAPA through her structure is able to reach over 40 million regular and faithful members of the Church in Africa through different gatherings that are routinely conducted on daily, weekly, monthly and yearly basis using her vast human resource (skilled and unskilled Priest and Volunteers) and institutions.”

Other groups have recognized the value of integration. The Global Fund sees its Health System Strengthening component as an integrated way of addressing institutional bottlenecks that threaten control of all three diseases, as does WHO. Some grant supported programs, such as in Swaziland, already aim to strengthen the integration of TB and HIV/AIDS services.

Treatment of people and communities in a holistic way is an important goal, and may even achieve greater efficiencies and strengthen health systems to provide a greater range of quality services, not just support vertical programs.

Can the Internet Become an Advocacy Tool?

Recently we discussed the value of the website for the Global Fund to Fight AIDS, TB and Malaria as an advocacy tool to get financial, policy and programmatic support for malaria programs. During a recent visit to Kenya I learned that for many NGOs and front line health service staff the internet is a dream at best. Members of civil society organizations complained that it is only those in a well financed NGOs based in the capital who can browse and receive email communication about the latest developments and thus be in a good position to act on new grants and information. This was reiterated by a key development partner who warned that we in the international development community and the national health and development agencies tend to forget that few people can or do access information about malaria funding and technical information through the internet.

internet-use-africa.jpgThe website, Internet World Statistics, helps make this problem graphically clear. Overall only 3.6% of people in African use the internet compared to 20.2% worldwide. In continental Sub-Saharan Africa, South Africa takes the lead at 10.3% while DRC and Ethiopia are lowest at 0.2%. Some of the isalnd nations where mosquitoes and malaria are more easily controlled have internet usage approaching world averages.

One assumes that with the wealth of free information on the internet, though obviously some of questionable quality that the internet would be a most valuable resource for health program planners. In Nigeria we learned that the digital divide seen between Africa and the rest of the world in the attached chart also extends within countries. In southwest Nigeria we found that staff of NGOs were 50% more likely than those of government health agencies to have access to a computer and to browse the internet.

There are a large number of free malaria e-mailings that go out frequently to subscribers. Most helpful is the weekly summary of malaria news and scientific articles from the Roll Back Malaria partnership. Even in Africa AMANET sends out an e-mail newsletter. Africa Fighting Malaria is another group that puts out regular news summaries. But these are of little value if one does not have reliable internet access.

Part of development assistance in the war against malaria therefore, needs to include internet access to government and NGO staff in Sub-Saharan Africa as a major component of its armament. This will enable African malaria workers to be on top of the latest developments and access the information and funds they need to succeed against this killer disease.

Ghana District Malaria Advocacy Teams Emerge

Advocacy efforts are needed at the district and community levels to ensure that national policies for a malaria free future are actually implemented. Emmanuel Fiagbey of Voices Ghana contributes this report on development of District Malaria Advocacy Teams (DMATs)

Working in close collaboration with the National Malaria Control Program, the District Health Management Team (DHMT), the District Assembly and other stakeholders, Voices Ghana has succeeded in laying the foundations for vigorously promoting malaria advocacy at the district level.

ghana-blog-photo-1.JPG DMATs have become functional in Asuogyaman and Keta Districts. The process was set in motion with a meeting of key stakeholders including traditional leaders, religious leaders and leaders of public and private sector organizations who discussed the malaria situation, ITN distribution and use, acceptance and use of the new malaria drug, availability of resources for malaria control programs, and developing effective partnerships for malaria control.

DMATs were formed with the goal of effecting change in malaria programming, policy implementation and improving resource mobilization for malaria control efforts. Membership includes members of the District Assembly, DHMT, NGOs, other key public sector departments, chiefs, religious leaders, private sector representatives, the media and the Police Service.

1212121212.jpgSo far the DMATs have defined their roles and responsibilities and formulated their advocacy action plans for implementation. Examples of activities include

  • Mothers and Fathers clubs for malaria control in 30 communities in the Asuogyaman
  • Sensitization durbars in selected communities on the new malaria drug policy
  • Private sector fund raising with organizations such as the Volta River Authority, Akosombo Textiles Ltd. Akosombo Volta Hotel, and Keta Salt and Fishing Industry
  • Labor union mobilization for malaria control in the work place
  • Malaria free clubs in schools
  • Consultative meetings with Parent Teacher Associations on strengthening early treatment and referral systems in schools
  • Ensuring all health facilities are equipped with ITNs
  • Create seed funds for Artesunate+Amodiaquine and SP to prevent stock-out
  • Consultative meetings with District Council of Chiefs and religious leaders
  • Creation of special ITNs funds to serve the needy
  • Malaria prevention and treatment education with women’s and men’s associations.

Civil Society, Private Sector and the Global Fund

A major decision at the 15th Board Meeting of the Global Fund to Fight AIDS, TB and Malaria (GFATM) was to strengthen the role of civil society and the private sector in the Global Fund’s work. This includes involvement at both Board and country levels. Not only should Country Coordinating Mechanisms (CCMs) be more representative of all the major players in the public, private and civil society spheres, but they should also ensure “routine inclusion, in proposals for Global Fund financing, of both government and non-government Principal Recipients (PRs) for Global Fund grants (“dual-track financing”).

The evolution of CCMs from government agency-donor clubs to bodies that represent the broader society of a country has been occurring in recent years as constituencies affected by and civil society organizations working to fight the three diseases have gained a greater voice. While this voice is growing, little has occurred in the way of major funding for civil society at Sub-Recipient (SR) level, let along through simple contracting with the PRs. Until civil society groups can become PRs in their own right, they will be speaking from the sidelines.

As reported recently, grants operated by NGOs perform better than those with government or UN agencies as the PR. With dual track funding, not only will NGOs and CSOs have an equal chance to manage grants, but possibly a healthy competition between government-managed and NGO-managed grants will lift the boat of performance for all.

CSOs and NGOs come in all sizes and functions. Many, especially ones indigenous to the grant-receiving countries, are new to the concepts and processes of the GFATM. Fortunately a quartet of NGOs has put together a guide entitled, Engaging With The Global Fund to Fight AIDS, TB and Malaria: A Primer for Faith-Based Organizations. This guide will in fact be valuable to all civil society groups, not just the faith community. It should help them understand the structures, functions and proposal writing steps at the country level so that they not only have a voice in the CCM but also have a voice and a hand in how critical AIDS, TB and Malaria services are provided.