Photo: Participants of the “Exchange for Change” workshop in Malawi. / 
Source: GIZ (Didrick Chirva)
The importance of communications among key actors in the health system and the need for mechanisms to ensure transparency and accountability –– These were recurring themes at two regional workshops organized earlier this year by the global GIZ program BACKUP Health. The workshops, in Burkina Faso and Malawi, were designed to explore common bottlenecks in implementing Global Fund–financed health programs and to design novel solutions to address them. The title of the workshops –– “Exchange for Change” –– reflected BACKUP’s goal to provide Global Fund partners with a platform for dialogue and mutual learning. Fostering South-South exchange is an integral part of the BACKUP Health approach to capacity development in countries implementing Global Fund grants for their HIV and AIDS, malaria and TB programs. One hundred representatives from civil society and state actors from 17 countries participated in the workshops. The countries attending the Burkina Faso workshop were Burkina Faso, Côte d’Ivoire, Cameroon, DRC, Guinea, Niger and Togo. The countries participating in the Malawi workshop were Ethiopia, Kenya, Liberia, Malawi, Namibia, Nigeria, Rwanda, Sierra Leone, South Africa and Tanzania. To make sure that the content of the workshops responded to the needs and interests of the participants, BACKUP conducted an online survey prior to the workshops. Participants were asked to reflect on the most important challenges they faced related to Global Fund processes and health program implementation. Many of the responses were about grant implementation, CCM functioning and health systems strengthening. BACKUP chose the innovative LEGO Serious Play method as one of the workshop tools. The method fosters creative thinking as it encourages teams to use LEGO bricks to construct tangible models of their working environments and the challenges and bottlenecks they face in it. Participants work through imaginary scenarios using visual three-dimensional LEGO constructions, which is why the method is called “serious play.”
Figure: Visualization of solutions on “How to use information and data for planning and decision-making by PRs”

Source: GIZ (Didrick Chirva)
“This methodology is quite amazing,” one participant from Liberia said. “I actually wondered what my child is going to say seeing me playing with LEGO. I gradually realized how things and situations can easily be brought to life which are normally so sophisticated! Portraying these rather complex situations into a model, which provides a short answer to your question, is great. Nobody in our group was left behind, all of us can easily explain our challenge and solutions as this method is so down to earth!” Mixed nationality breakout groups were formed to work on topics (called “challenge models”) that participants selected from the list of topics generated by the pre-workshop survey. In the Malawi workshop, the breakout groups worked on the following topics:

• Inadequate use of information and data for planning and decision-making by PRs
• Dealing with grant management risks and reporting challenges
• Selection of PRs and SRs: a transparent and objective process?
• Interacting with national coordination bodies
• Capacity building of community-based organizations / Capacity of networks to engage in Global Fund processes
• Coordination for design, prioritization and implementation of HSS interventions
• Insufficient direct national funding to health and especially to HIV, TB and malaria

Participants in the Burkina Faso workshop selected the following topics for the breakout groups:

• Supply management
• How to address gender-related and human rights–related issues in Global Fund programming
• Role and functioning of CCM secretariats
• Integration and alignment of CCMs with national health coordination structures
• When and how to do strategic grant oversight
• Producing CCM dashboards
• Integration and alignment of community interventions with national guidelines and standards
• Capacity building for SRs and sub-SRs

For each topic, participants had to jointly construct three consecutive scenarios: the challenge; the ideal situation; and the solutions. The solutions part of the exercise allowed participants to take away from the workshops something concrete to build on upon return to their home country. One group worked on a challenge that had been identified in Guinea where the CCM’s oversight committee is struggling to collaborate with implementers and to successfully perform its oversight role. Participants said that the ideal situation was well-organized collaboration among the oversight committee, the principal recipients and the sub-recipients. Among the solutions they identified was that it was important to clarify the roles of actors involved in grant oversight; and that the capacity of implementers to collect quality data needed to be strengthened so that implementation bottlenecks could be identified at an earlier stage. Another group chose to work on a challenge from Nigeria –– the limited coordination at country level which prevented implementers from designing and implementing effective health system strengthening interventions. The group said that the ideal situation was the creation of one national coordination body to manage health systems strengthening resources, and that this body would have the mandate to allocate funds based on joint planning and a health systems strengthening strategy. The solutions identified by the group included that Nigeria needed to initiate discussions about a health systems strengthening investment strategy; and needed to develop an operational plan so that funding could be allocated systematically to achieve joint impact. A third group worked on a challenge from Côte d’Ivoire –– the need for integrating and aligning CCMs with national health coordination structures. The group described the ideal situation as having (a) the CCM anchored in the Office of the Prime Minister; (b) improved communications; and (c) an officer providing liaison between the CCM and health partners. The solutions identified by the group included: (a) identifying TA needs; (b) developing a transition roadmap; and (c) establishing a steering committee to manage the transition. One of the participants in this breakout group said that many CCMs do not dialogue with other health sector coordinating mechanisms and that, as a result, the CCMs were missing out on opportunities to avoid duplication and ensure that the various programs were complementary. This person explained that the idea of having CCMs anchored in the Prime Minister’s office, or other high level, is linked to the belief that issues and bottlenecks are more easily resolved at this level; and that given the multi-sectorial nature of the CCMs, decisions of the CCM are likely to have greater weight. In addition, given that CCMs need more funding to function effectively, having a high-level government representative on the CCM should make funding easier to come by. Another member of this group, from Côte d’Ivoire, commented that the presence of representatives of four or five CCMs, each with its own particular structure and experience, “allowed us to identify our challenges and also to find adequate solutions for our own case.” The table below describes two additional challenges that workshop participants tackled.
Table: Two of the challenges addressed during the breakout sessions

Country	Malawi
Challenge	Low capacity of community-based organizations and networks to engage in Global Fund processes.
Ideal situation	CSO community representatives are capacitated and have communication channels to the CCM, thereby strengthening the role and composition of the CCM. There is a bridge between PRs and SRs to reach communities, and the communities play their watchdog role.
Solutions	Strengthen capacity of CCM composition to ensure local organizations are represented by articulate, knowledgeable and experienced representatives. Increase the number of key population CSOs represented on the CCM. Build the capacity of key population CSOs to move from SR level to PR level. Increase SRs’ awareness of budgets agreed between the LFA and the PR. Strengthen social accountability. Implement community score cards.
Country	Cameroon
Challenge	(1) Need to eliminate social, cultural, religious, legal and political barriers, especially stigma and discrimination, that key and vulnerable populations experience when trying to access health services. (2) Insufficient capacity building for implementing and monitoring gender-related and human rights–related activities.
Ideal situation	Key and vulnerable populations have unrestricted access to universal health services.
Solutions	Advocate for the government to adopt/improve and apply the necessary laws (with the involvement of key and vulnerable populations). Provide accessible materials and training to sensitize communities. Mobilize human, technical, financial and material resources. Implement gender-responsive programs (training, awareness raising, M&E). Establish a mechanism to monitor human rights dimensions.

In addition to the interactive group work, the workshops featured presentations of lessons learned, networking sessions and a dialogue between the BACKUP team and participants to discuss technical assistance needs. “The space created by BACKUP makes sure that the lessons learned are shared between different countries,” a participant from South Africa said. “It is a nice way to understand the root causes of problems and diving deeper into the process of finding a solution for that. A lot of the discussed topics, insights and recommendations from the other countries were so helpful….” Dr. Klaus Peter Schnellbach, Head of the BACKUP Health program, said: “We wanted to provide a space that is really interactive and that is really favorable to an exchange and mutual learning –– and the feedback we have received shows us that this has worked.”
For further information, watch a short film of the workshops
here
. The latest issue of the BACKUP Health newsletter describes a new process and guidelines for applications for funding from the initiative. The newsletter also contains articles on strengthening governance and oversight functions of the CCM in Rwanda; regional dissemination workshops in Burkina Faso to build broad-based understanding of HIV, TB and malaria; and the first German secondment to the Global Fund Secretariat. The newsletter is available
here
. General information on BACKUP Health is available
here
.

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