Balancing accountability and adaptability: potentializing the impact of HIV/AIDS programs in the Maghreb Region through the Global Fund’s support
Author:
Mohammed El Khammas, Coalition PLUS/MENA Platform
Ines Alaoui, Coalition PLUS
Lahoucine Ouarsas, Coalition PLUS/MENA Platform
Naoual Laaziz, Coalition PLUS/MENA Platform
Estelle Tiphonnet, Community Health and Public Health Independent consultant
Mehdi Karkouri, Coalition PLUS/MENA Platform
Article Number: 5
A study recently commissioned by the Coalition PLUS MENA Platform analyzed Global Fund management procedures and the implementation of related activities in four Maghreb countries: Algeria, Mauritania, Morocco and Tunisia. This article builds on the main findings of this study and makes targeted recommendations to the Global Fund. Although developed with a regional focus, these insights aim to benefit broader efforts to improve program operationalization.
Introduction
Since its establishment in the Maghreb region (Northwest Africa) in 2003, the Global Fund has significantly and undoubtedly boosted the professionalization of local organizations and structured HIV/AIDS programs. This has largely been achieved through the implementation of rigorous management standards and the empowerment of local stakeholders, especially the communities involved. However, the players involved regularly note a lack of flexibility and adaptation to contextual realities and community work, notably the unsuitability of certain standards in the context of work with vulnerable populations.
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A study recently commissioned by the Coalition PLUS MENA Platform analyzed Global Fund management procedures and the implementation of related activities in Algeria, Mauritania, Morocco and Tunisia. These constitute four of the five Maghreb countries (Libya is the fifth, which is not included in the study).
The study found that all stakeholders are keen to ensure that programs and activities run as smoothly as possible. However, donor constraints often cascade down to the Global Fund country teams, grant managers and other local players, impacting their ability to adapt programs to local realities. All four countries share similar administrative and operational issues in implementing Global Fund-supported programs. The emphasis on financial accountability often results in excessive administrative burdens, reducing the time and resources devoted to strategic and community-based activities in response to pandemics.
This article builds on the main findings of this study and makes targeted recommendations to the Global Fund. Although developed with a regional focus, these insights aim to benefit broader efforts to improve program operationalization.
Algeria and Tunisia: a multi-country approach to vulnerabilities
The upcoming multi-country grant for Algeria and Tunisia, managed by the United Nations Development Programme (UNDP) as Principal Recipient (PR), represents an important step forward in addressing the specific vulnerabilities of these two countries. The two nations share similar challenges in terms of community involvement and efficiency in the management of Global Fund-supported activities. For the Global Fund, the presence of a single PR, managing cross-border grants, aims to capitalize on synergies and encourage mutual learning.
However, there are concerns about a potential lack of ownership and commitment from national authorities as a result of this international management of grants and, therefore, the sustainability of activities in a context of incipient transition remains uncertain. To address this issue, it is essential that UNDP actively supports national players, particularly community-based organizations, through capacity-building initiatives, and ensures that local authorities are fully integrated into decision-making processes. The creation of collaborative channels between local entities and the UNDP would additionally strengthen the sense of ownership of the stakeholders.
In Tunisia, the economic precariousness of peer educators is a major issue. Despite their crucial role in engaging key populations in the national response, inadequate compensation leads to high turnover and job insecurity. UNDP, as the new PR, must address this issue by negotiating improved compensation and ensuring better working conditions to retain these essential workers.
Tackling structural obstacles to implementation in Mauritania
Mauritania faces additional complexities due to the Global Fund’s Additional Safeguard Policy (ASP). Although the ASP aims to reduce financial risks, its onerous administrative requirements have delayed activities, limited the capacity to adapt to realities on the ground, but above all have led to limited country ownership.
Moreover, like Morocco, Mauritania is a “focused” county under the Global Fund’s operational model, which means that the Global Fund country team is smaller and has fewer human resources to oversee implementation. As a result, the PR, the National AIDS Control Executive Secretariat (SENLS), often lacks adequate support to effectively coordinate grant activities, or has to wait, at times for an extended period of time for responses from the Global Fund Secretariat.
The report also highlights the challenges of engaging local civil society organizations (CSOs). Many of these CSOs feel they are treated more as service providers than partners. They are not involved in grant making and find themselves having to implement activities – which they have had little opportunity to discuss – in relation to the constraints of key populations. This perception limits their capacity to influence the strategic appropriateness of programs. To address this situation, the Global Fund must ensure that civil society is involved in negotiations, and encourage joint decision-making between PRs and CSOs, making the most of the expertise and context-specific knowledge of grassroots organizations.
Morocco: striking a balance between financial control and programmatic impact
The Moroccan Ministry of Health and Social Protection acts as PR and effectively manages the financial aspects of Global Fund grants. However, financial procedures pay little regard to the final beneficiaries, particularly when it comes to reaching marginalized populations. Peer educators in Morocco face the same challenges as in Tunisia, with insufficient compensation and an uncertain status, threatening the sustainability of their involvement.
Our report suggests that Morocco’s centralized approach has sometimes alienated local CSOs, who feel that their contribution is undervalued in wider strategic discussions. As a result, these organizations are less able to adapt activities to the local context, which is essential in a diverse country like Morocco. In the future, it will be important to leverage the role of CSOs by valuing their knowledge of the field and granting them sufficient autonomy to improve the quality of interventions.
Recommendations
Adjustments still need to be made to strengthen the impact and sustainability of Global Fund programs in our countries. Greater flexibility in financial procedures is crucial and would make programs more accessible to the most marginalized populations. This would include, for example, systematizing the possibility of extending the use of cash payments or mobile payment systems to beneficiaries without bank accounts, as it has been successfully implemented in other countries, notably Mali. This issue is particularly critical for the inclusion of vulnerable program populations, in rural areas or among key populations, who have no access to conventional banking services.
Strengthening partnerships is a prerequisite for greater local ownership of grants. In the Algerian and Tunisian examples, local entities need to be fully engaged as genuine partners, actively involved in strategic decisions and given real opportunities to contribute to program direction.
The issue of remuneration and the safety of peer educators require priority attention. In the four countries, improving their working conditions is urgent, particularly to reach the most vulnerable populations, but also as a key function of sustainability. The Global Fund and the countries concerned (and in particular the Ministries of Finance) must support the standardization of contracts to ensure fair remuneration and job security.
In contexts where needs can evolve rapidly, or simply where there are long lead times between grant negotiation and start-up and implementation, it is advisable to facilitate the reprogramming and adaptation of activities. Simplifying the reprogramming process makes it easier for partners to adjust to economic fluctuations or changes in population needs, thus contributing to more responsive program implementation. This recommendation would be particularly relevant in the Mauritanian context.
The Global Fund must respond to the need for capacity building and technical support when CSOs and PRs encounter difficulties in meeting its rigorous requirements. By increasing technical assistance in these targeted contexts, the Global Fund would help fill the human resources gap, particularly in small country teams.
Finally, the multi-country approach in Algeria and Tunisia may represent a valuable opportunity to promote shared learning and good practices. However, the Global Fund should encourage the setting up of transnational collaboration platforms to draw on each other’s experiences and improve the overall effectiveness and impact of interventions.
Conclusion
The issues raised in this report are neither new nor resolved: they testify to a persistent imbalance in the Global Fund’s risk management, which has historically focused more on financial risk than on programmatic performance. This prioritization can lead to underperformance or lower programmatic performance when activities are not adapted to the real needs of communities. However, achieving results in such complex contexts requires us to accept certain risks, particularly those that enable us to respond to local issues and reach the most vulnerable populations. By adopting a more flexible approach and strengthening local partnerships and capacities, the Global Fund and its PRs can not only maintain financial rigor, but also maximize the impact of investments with sustainable results for the countries’ public health – at the very least in the case of Algeria, Mauritania, Morocco and Tunisia.
