Board Thematic Discussion on Communities at the Center
Article Number: 2
ABSTRACT : For the first time, the Global Fund Board meeting held thematic discussions on two topics, one on gender and the second on communities. This article summarises the Board discussion paper on Communities at the Centre, which informed the discussions of this issue at the 48th Board meeting in November 2023.
The Global Fund Board meeting in November 2023 held two thematic discussions, one on Gender and another on Communities. We reported on the gender thematic discussion in December’s GFO and in this issue we highlight the key points of the discussion on communities. The Board paper, Thematic Discussion: Communities at the Center is available here.
The Fund’s ambition regarding Communities at the Center
The new Global Fund Strategy: Fighting Pandemics and Building a Healthier and More Equitable World places people and communities front and center of the fight against HIV, TB, and malaria (HTM). The Strategy will accelerate the shift towards people-centred prevention, treatment, and integrated care models. It commits to putting “communities at the center” of the global HTM responses, explicitly acknowledging that the failure to do so “has resulted in suboptimal programming and health outcomes.” Implementing this commitment requires the advancement of two distinct areas of work:
- Supporting the deepened leadership and engagement of communities in decision-making and processes that directly impact their health; and
- Strengthening the role of communities in designing, managing, delivering, and overseeing impactful HIV, TB and malaria programs and the systems that support them.
The Global Fund intends to catalyze its work and efforts in responding to the needs of communities living with and affected by the diseases. It plans to deliver this through the Strategy’s mutually reinforcing contributing objectives of “maximizing people-centred integrated systems for health, to deliver impact, resilience and sustainability; maximize the engagement and leadership of most affected communities to leave no one behind; and maximize health equity, gender equality and human rights.”
The Fund’s ambition regarding communities at the centre
To achieve the purpose as laid out in the 2023 – 2028 strategic framework, the Fund will work in three distinct areas: community engagement, community system and responses and bolstering the role of community health workers (CHWs). Each area of work is discussed below:
The new Strategy fully acknowledges the importance of community engagement as a key element in its ambition of communities at the centre. It includes the Mutually Reinforcing Contributory Objective: maximizing the engagement and leadership of most affected districts to leave no one behind. By the Strategy’s mid-point (three years), the Fund’s ambition is to see progress in three areas:
- Demonstrable enhancements in community engagement and leadership across the grant life cycle.
- Improved Global Fund policies, processes and approaches informed by community evidence.
- Clear roles, responsibilities, and accountability in the Secretariat and the Global Fund Partnership.
Figure 1. Illustration of the steps changes in community engagement to deliver the new Strategy
To achieve this, the Fund acknowledges that it needs to change how the partnership approaches community engagement. In practical terms, this will include both evolving existing approaches and introducing new ones:
- Introducing Community Engagement Minimum Expectations and adapting business processes.
- Addressing representation gaps and improving inclusion in and transparency of Country Coordinating Mechanisms (CCMs) through regular composition review and election support.
- Evolving the Community Engagement Strategic Initiative to expand differentiated country-level support to criminalized, marginalized, excluded, and most vulnerable populations.
- Strengthening coordination and alignment with partners, including community stakeholders.
- Introducing a Community Engagement Key Performance Indicator (KPI) and regular community-led evaluations.
The new Minimum Expectations for community engagement (CE) at three stages across the grant life cycle respond to multiple assessments, which have shown that CE across the entire grant life cycle remains variable, with weaknesses more pronounced during grant-making and implementation oversight.
Figure 2. Operationalization of the community engagement minimum expectations across the grant cycle
The three expectations are:
- Funding Request and Allocation Letter: A transparent and inclusive consultation process with populations most impacted by HTM (across gender and age) during Funding Request development resulting in an Annex of Funding Priorities of Civil Society and Communities Most Affected by HTM as an output.
- Grant Making: Community and civil society representatives on the CCM have timely access to information on the status of grant negotiations and changes to the grant to support their involvement in oversight.
- Grant Implementation: Community and civil society representatives on the CCM have timely access to information on program implementation.
Community Systems and Responses (CS&R)
The Secretariat has widely acknowledged that strengthening community systems and responses through a tailored and differentiated approach is needed to actualize its ambitions. By the Strategy’s mid-point (three years), its ambition is to see progress in four areas:
- The advancement of approaches that strengthen the contribution of community health cadres, including vital and vulnerable population peers, peer paralegals and treatment supporters, and community health workers towards aligned systems for health.
- Strengthened platforms for service delivery through community-led and based organizations that allow flexible, people-centred service access options for clients.
- Increased access to funding for community-led organizations, particularly those led by key and vulnerable populations across the three diseases.
- The practical and routine use of community-led monitoring (CLM) data and feedback in program implementation oversight.
Community-Led and Based Responses (CLO/CLR)
In this area of work, the Fund intends to measure its investments in community systems for service delivery, advocacy, and research; evolve its business processes and grant implementation arrangements to ensure funding to CLO/CLR; strengthen the continuum of care, including redress to social, cultural, and political barriers that undermine access to services; and improve Secretariat-wide capabilities on CS&R. To achieve these objectives, the Fund commits to
- Adjust internal ways of working to achieve the ambition:
- Facilitate cross-partner CSS/CLO/CBO responses via a coordination platform (potentially evolve existing platforms, e.g., Situation Rooms) to drive joint accountability and alignment.
- Develop and implement a plan to evolve the system and process capacity for monitoring and tracking investments and program coverage by implementer type, including below the Principal Recipient and Sub-Recipient levels.
- Leverage the integrated risk management module (IRM) 2.0 resilient and sustainable systems for health (RSSH) sub-risk to comprehensively assess all aspects of CS&R with a focus on CLOs – guidance under development.
- Introduce and ensure concerted efforts to achieve the targets of the new civil society strengthening (CSS) KPI. Focus on priority countries to support key stakeholders across the grant life cycle for community systems strengthening and scale up effective community-led and -based responses; use a range of levers, i.e., allocation letters, matching funds, Strategic Initiatives (SIs) differentiated across the portfolio.
Community Health Workers
CHWs and the underlying systems that support them are vital for increasing access to quality, integrated, people-centred services, including for HTM and broader primary health care; building surge capacity to surge and readiness to scale; boosting multi-pathogenic pandemic preparedness capabilities among the most vulnerable communities and populations; and providing employment and decent work, particularly for women and thus an essential means to address gender equality in the health and care workforce. By the Strategy’s mid-point (three years), the Fund’s ambition is to see progress in three areas:
- A shift from piece-meal approaches to comprehensive and well-designed investments across system components.
- Evolution from short-term toward more medium/long-term planning with support spanning funding cycles and accelerated development of sustainable financing pathways.
- Larger scale investments.
Figure 3. A phased approach for bolstering the role of community health workers
The presentation to the Board concluded with a request for the Board to consider five questions:
- How can we better articulate roles and responsibilities across the Partnership and hold ourselves and our partners to account for delivering on community engagement and community systems and responses?
- What practical steps can we take to mobilize the whole Partnership to deliver our collective strategy commitments on community engagement and community systems and responses?
- Do we need to rethink and redefine what success looks like to us as a Partnership across these areas, including how we hold ourselves to account and demonstrate accountability to communities?
- How do we more effectively engage our partners, including implementor governments, to strengthen community engagement as a fundamental principle and practice in the national program, policy setting, and decision-making processes?
- How can the Partnership work more effectively to pursue and progress a comprehensive approach to community responses and systems that recognizes as equally critical community-led and based organizations and community health workers situated within ‘formal’ methods?
The Board had robust deliberations on the topic, with several Board constituencies focusing their interventions on the ‘strategic how’ the Fund will ensure that communities are indeed at the center of all its programs throughout the Strategy. Several constituencies affirmed that the Fund’s actions to place communities at the center should not only be concerned with the Fund’s partnership approach at the global level. Instead, the focus should be on country-level grant implementation. With support from a cross-section of the donor and implementor delegations, the Board’s civil society delegations made effective contributions on the need for investments in community systems, the role that key affected populations and communities play in the delivery and implementation of the Global Fund grants and the importance of the Global Fund being able to leverage its diplomatic voice to address the structural determinants of health, such as a lack of human rights protection for these communities.
The Board also discussed how the Global Fund could use its diplomatic voice to reinforce the theme of placing communities at the center through grant allocation letters. With solid support from the donor and implementor constituencies, there was agreement that grant allocation letters could be used as a lever to reinforce the importance of gender equality and focus on the priority program areas of the communities and promote the Fund’s investment in RSSH.
Responding to these concerns, the Secretariat noted that it understands the concerns raised with Peter Sands, stating that with solid investments in community systems, the Fund will deliver on the ambition of the new Strategy. The session ended with a commitment to examine how to involve the Community, Rights and Gender (CRG) department in management processes and decisions.