Country-led and community-owned? How cultural imperatives at the global level translate on the ground
In my seven years as a technical advisor to the National Department of Health in Papua New Guinea, I watched the evolution of the relationship between the country and the Global Fund.
Through good times and the dark days of 2010-2011 when (all of our programs were audited by the Office of Inspector General, and the government’s subsequent relinquishing of the Principal Recipient role) I experienced first-hand the challenges of developing meaningful engagement between a health system in perpetual crisis and a multilateral funding institution that sometimes appeared at odds with itself.
The focus on the three diseases had exposed larger cracks in the health system that prevented effective delivery of services related to the three diseases.
This left the country trying to balance the quick-fix service delivery solutions mandated by performance-based financing against its need to undertake larger health system reforms to improve resilience and its ability to reach communities for multiple health issues. The Global Fund processes were inadvertently weakening the very health system it was trying to support.
So it was with great interest that I began a 40-hour journey in July to attend the Partnership Forum in Bangkok: the latest in a series of consultations to cement the culture shift at the heart of the Global Fund into its next strategy, building on internal reforms that are transforming the Fund into an organization that is focused on building and maintaining partnerships not just with institutions but with the people within those institutions.
The draft five-year strategy shared with Forum participants certainly reflected these ideals, emphasizing partnerships, the development continuum, country ownership, resilience and community engagement. This new strategy shows that the Fund is responding to the changing landscape of health and development, where despite great advances against the three diseases, inequities still exist and social and economic progress is further widening the chasm.
The presentations from the Board and the Secretariat were optimistic and hopeful, reinforcing that communities are central to closing the inequity gaps and cannot be left behind in order to end the epidemics. The large civil society and key affected population representation at the forum seemed to be at one with the mantra.
But for all the congeniality and celebration, there was no shortage of deep issues lurking beneath the surface, underpinning concerns expressed by a number of civil society representatives.
In becoming more focused on ‘human beings’ the Global Fund has made communities, systems, rights and gender core objectives of its strategy. This is smart thinking that builds on the new funding model’s own goals of supporting “coherent, country-owned, national health strategies that engage all sectors in design and implementation.”
But it also remains loftily theoretical, and not – as it should be – predicated on actual evidence of the success of NFM country-level engagement in improving community participation.
Most of the conversations I had with Forum participants representing 15 countries circled back to the same complaint: while the Fund is an agent of change for getting community members to the table, it remains tokenistic, ad hoc and does not actually result in community voices guiding decision-making on interventions, targets or resource allocation.
This tokenism is reinforced by the requirement to document and provide evidence of the participation of communities, specifically key affected populations, in the NFM. Rather than being empowered to participate, community members felt coerced into attending meetings so that their names would be registered on an attendance sheet that was submitted to the Fund to demonstrate that quotas had been met.
Others spoke of technical consultants and government officials arriving at those meetings without notice, offering ‘pre-cooked’ documents for endorsement that did not allow community members the time to consult with their constituencies and offer feedback.
So it’s here that the Global Fund’s challenge lies: closing organizational gaps between its theoretical ideology of partnerships and community engagement, and its risk management priorities. Despite the significant organizational reforms undertaken in the lead-up to, and implementation of, the NFM, the ‘receipt culture’ still permeates all aspects of the Fund’s business processes, including the country dialogue.
This seems counter-intuitive to fostering a genuine environment at country level that enables communities and groups to collectively set their own agendas and address the problems they prioritize. Additionally, the pressure for countries to focus on key affected populations has the potential to skew genuine participatory processes, and risks inclusion of ‘quick-fix’ interventions to address the criteria for funding.
Such quick fixes will no doubt work against the very principles of participatory approaches that let communities determine their agendas and solutions for sustainable change.
If the Global Fund is really serious about fostering participatory approaches that can result in overcoming profound disempowerment and lead to building systems for health, then it needs to consider a better way to operationalize them. It’s not enough to tell countries they need to do something to meet a requirement; it’s about encouraging the transformation of national systems into mechanisms that marry accountability and transparency with support for human rights and shared responsibility.
The future of the Global Fund depends on strong and inclusive community and health systems, which is why the Fund must reconcile its risk aversion and business practices with its desire to foster genuine community participation and country-level partnerships if it is to achieve the lofty ideals in the new 5-year strategy.
The challenge is now set for the Board and the executive team to listen to the views coming from the ‘bottom up’ at country and community level through these Partnership Forums and translate them into meaningful and supportive operational policies for Global Fund grants that truly engender partnerships and participation.
Anna Maalsen has worked as a technical advisor for several governments on issues related to Global Fund grant implementation. The opinions in the above commentary are her own.