Do Global Fund catalytic investments promote a resilient health system based on improving community systems?
Article Number: 5
Decoding three key concepts devoid of meaning
ABSTRACT Following on from our popular and light-hearted look at Global Fund language or, as we call it, Fundspeak, we now turn our attention towards some commonly used but equally baffling phrases used by the Global Fund.
The recent publication of Oliver Campbell White’s article on the use of the English language in Global Fund documents was widely read, as our website traffic shows. Proof that we all have a sense of humour, Aidspan received positive feedback and support to our call for an “Plain English policy whereby words are used properly”.
We can only support this criticism because who among us, confronted on a regular basis with the Global Fund’s writings, has not complained about a pompous style, endogenous concepts that are difficult to understand, and simplistic intervention progress schemes that are far removed from our reality.
But our world is not simple, and as former President Obama said in an interview with the radio station France Inter in 2021, the power of words has been put into the hands of millions of people who misuse them, creating what he labelled “an epistemological crisis”. He called for caution in mixing reality and fiction in a world where everything is potentially manipulatable.
It is this issue that needs to be looked at carefully when analysing the Global Fund’s theory of knowledge. While it is true that linguistic peculiarities and the abuse of incomprehensible expressions is commonplace, as our colleague has described, one cannot help but wonder what these phenomena produce for thinking. Doesn’t the fact of using expressions that are incorrect, of abusing expressions or words like “strategic”, of inventing neologisms that exist only in the Global Fund, create a parallel reality that is only present in Geneva, with the corresponding risk of never translating these concepts into the tangible reality where the Global Fund’s investments will have an impact? Let’s analyse the Global Fund’s creation of a ‘universe’ of its own without existence, which mixes fiction and ideological bias.
Global Fundspeak: ‘catalytic’
Many Global Fund documents use expressions that are close to neologism, or whose contours are blurred: one of the best-known examples is the word ‘catalytic’, which is used to define a grant (‘catalytic funds’), an effect (‘catalytic actions’) or an action. The term is English-speaking and has no valid translation in the French dictionary, although French speakers have become accustomed to speaking of ‘catalytic funds’. There are no criteria for what is catalytic, which really raises the question of its operational translation. The team of external consultants responsible for the evaluation of the catalytic funds were confronted with this lack of definition and, with the impossibility of judging the ‘catalytic’ character of the grants awarded, the analysis of their added value was beyond them. They concluded, with some embarrassment, that there is no consensus within the Global Fund on what determines ‘catalytic’. On its part, the Technical and Evaluation Reference Group (TERG) noted that “the catalytic nature of these investments would be better operationalised if the Strategy Committee facilitated a consensus on the definition of the catalytic impacts expected from these modalities, including the risk if they are not implemented; and high-level principles to guide the selection of themes that would best achieve this impact”. In other words, the lack of a definition, and of a concrete and operational translation of this concept, makes its impact difficult to assess, especially as these grants receive little attention. Yet we urgently need strategies that make a difference and leverage the response in such crucial areas as finding undetected TB patients.
It is even more surprising when the concept is used in key documents, such as the narrative of the new Global Fund Strategy. The Strategy cites the word 14 times, in several forms: people-centred catalytic investments; partnership catalysts; development of policy, regulatory and programmatic catalysts; ensuring confidentiality through the use of other catalysts; catalyst for responsible, ethical and sustainable procurement and resilient supply chains… our first reaction is one of astonishment and the impression that such repeated use of this concept, which we understand must remain specific and provide exceptional effect, dilutes the concept and ‘normalises’ it. All the actions mentioned in the new Strategy seem to be catalytic, so it should be understood that this is simply the Global Fund’s search for impact and added value. In the absence of a definition and common understanding of the concept, as requested by the TERG, no more can be said.
The false reality: ‘Community Systems’
Another concept that we find questionable is that of ‘community systems’, which is widely used at the Global Fund. It first came up in the preparation of grant applications for the NFM3 round, was reinforced during the COVID-19 Response Mechanism applications and will undoubtedly rear its head again for NFM4. The technical briefing document states that ‘community systems’ is an umbrella term that describes the structures, mechanisms, processes and actors needed to support community responses. Community systems include different types of formal and informal community groups, organisations and networks, as well as other civil society organisations. They are an essential part of a country’s overall health system, working in conjunction with other stakeholders and sectors, such as government and the private sector. It should also be noted that the Global Fund uses the following operational definition of community for funding applications: ‘people who are affected by HIV, TB and malaria’. This includes ‘key and vulnerable populations’.
The reality of community engagement does not fit the definition or characterisation of systems, which give the illusion of logical structuring and interface between different systems. In fact, the grants cover different actors, namely: community workers who depend on the health system (community health workers, community adherence counsellors, etc.), activists from patients’ rights organisations, community-based organisations (women’s groups, youth groups, groups for young children’s nutrition), and so on. Identifying all these entities poses many challenges in countries, so it is difficult to integrate new actors into the grant, especially for TB and malaria, which have a more recent or less visible community history than HIV. They are often distant from community health workers, just as the health system is still relatively impervious to civil society actors, except for HIV and sometimes TB programmes. We are still far from seeing the formalisation of systems, let alone the creation of bridges or interfaces allowing for formal, organised and coordinated community dialogue between different interacting ‘bodies’. This is the nature of systems, and it is an attractive idea for a donor such as the Global Fund. However, the question of what people want must be asked, because community dynamics are by nature beyond the power of norms and evolve according to the characteristics of the society in which they develop. It is often an attempt by governments or donors to organise them, finance them and guide them in their orientations that has penalised these actors. The active participation of civil society in the fight against COVID-19 has shown how useful low-cost, locally rooted citizens’ initiatives have been, without the intervention of ministries or donors.
The conceptual error: ‘resilient health systems’
A final example is the concept of resilience. The Global Fund’s ambition is to build resilient and sustainable health systems, and the TERG notes from 2020 that ‘the Global Fund has taken some leadership in promoting the concept of resilient health systems, which is gaining ground in broader forums (…). As such, the Global Fund has entered into a number of partnerships to promote HSS and UHC, including the UHC2030 strategy’. In the 2017-2023 strategy, the Global Fund described this resilience as the ability of the health system to withstand shocks from epidemics, such as Ebola, but also COVID-19. It is about working on the capacity to adapt to contexts of fragility and vulnerability. But the concept is multifaceted, and that is its richness, since it has existed since the 1940s. Initially perceived as the ability to survive a trauma, a sort of inherent property of certain individuals, this concept has evolved into a dynamic process, in which the subject of study and its environment interact. The latter is seen as an entity that generates risks but also resources. In this way, the system and its environment become the object of intervention and study in equal measure, because no system is ‘born resilient’, it becomes so through the effects of the environment on its development and survival. If we accept this definition, we understand that the Global Fund’s investments to help make health systems resilient to shocks are not properly thought out today, and that their operational translation is not accurate. To support the process of resilience, it would first be necessary to study, in some detail, the environment, the factors and occurrence of shocks, the nature of these shocks and how they affect the health system, and more importantly, access to care for patients. This has not so far been the direction of investment in a resilient health system, although the funding provided for COVID has opened a gap. The new Strategy, which incorporates emergency preparedness, may help to operationalise the concept of a ‘resilient health system’.
This article is only a brief demonstration of the misuse of the language which we have become accustomed to at the Global Fund. But it must be recognised that defining terms is a necessary precondition for a mutual understanding of the mission, the expected results, and their evaluation. The Global Fund is among donors who are defined as “an efficient donor in evaluating results and achievements”. And the Global Fund’s track record speaks for itself… 40 million lives saved since 2002, more than 21.9 million people put on antiretroviral treatment… there is no need to resort to these lingusitic acrobatics, these sexy concepts that do not translate the reality we know and interact with every day, at all levels.