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GFO Issue 392



Christelle Boulanger

Article Type:

Article Number: 2

ABSTRACT Faced with the widespread belief that inadequate funding for civil society organizations is due to the lack of tangible results, one needs to analyze the factors that make community-based organizations dependent on donor assistance, assign them a predetermined role in the fight against pandemics and formulate a plan for the next strategy.

Several observers agree that the positive and concrete impact of the activities carried out by civil society organizations (CSOs) have not been accurately measured and proven. It is also widely agreed that this is the reason that these organizations do not get the attention and resources they need to implement their activities:

  • The Euro Health Group’s mid-term review of the 2017–2022 strategy recommended that greater efforts be made to strengthen interactions between civil society organizations and governments, provide evidence of the added value of CSOs, and to avoid conflicts of interest between CSOs acting as advocates for vulnerable groups and those providing services.
  • At the last webinar organized by the Global Fund’s Community, Rights and Gender (CRG) team on 5 November 2020, five regional civil society platforms discussed the challenges related to COVID-19 and how CSOs overcame difficulties in trying to provide information and services to the most vulnerable populations.
  • CSOs themselves, following the grant renewal process, stated that once again organizations were excluded when the final financial decisions in the grant-making process were made, but are required to act in partnership with the Ministry of Health.


It is easy to base the reason for the lack of CSO funding on the lack of proof of performance. However, it is ironic that it is these organizations that have been highly effective during the current pandemic.

There is enough evidence to show that the actions of CSOs are effective. Organizations that receive funding from the Global Fund or from donors such as the U.S President’s Emergency Plan for AIDS Relief (PEPFAR) are held accountable both for the impact of their activities and for the use of funds. They are required to complete indicator matrices, and those caring for patients are required to keep records of the number of patients in their care, the quality of care provided, and the number of patients lost to follow-up. Some community organizations that started working on tuberculosis (TB) were able to, within just a few years, identify a great number of missing cases in countries that had not reached new case detection levels, and to maintain them in treatment. This is the case of Alliance Côte d’Ivoire, or For Impacts in Social Health (FIS) in Cameroon. Since community interventions are suspected to lack cost-effectiveness, some CSOs such as ARCAD Santé PLUS (Association pour la Résilience des Communautés pour l’Accès au Développement et à la Santé) in Mali even collaborated with health economists to evaluate the cost of their strategies and their cost-effectiveness, which are particularly important to donors.

Ironically, it was the community-based initiatives that have helped maintain the relationship with isolated, confined and stigmatized patients during the COVID-19 pandemic. Extremely concerned about the effects of COVID-19 on patients and the progress made in fighting the three diseases, CSOs conducted studies and surveys, updated their cohorts, and sounded the alarm about the consequences of COVID-19. Those consequences were patients lost to follow up, interrupted HIV and TB treatment, greater discrimination and police harassment of key populations, reallocation of HIV and TB resources to COVID-19 testing, impoverishment of fragile patients, and adverse effects on patients’ mental health due to insecurity about their future and isolation experienced during lockdowns. In the face of a myriad adverse consequences, community-based approaches have, despite their modest means, helped to meet patients’ needs. They are trained to communicate with vulnerable groups in simple and appropriate language, and to quickly identify the most pressing needs (such as maintaining treatment, providing financial support or purchasing essential products).

It is therefore rather ill-considered to justify the lack of sustainable and structured support to CSOs by a lack of results. It is necessary to provide solutions to break this cycle which hampers progress in this matter. The following are some avenues for reflection:

  • CSOs have often highlighted their struggle to access resources, especially when having to compete with State actors or Principal Recipients. Notably, the Global Fund does not reserve a minimum percentage for CSOs while granting allocation. This allows them to participate in the country dialogue and influence the choice of activities that would ultimately be funded. Some organizations are advocating that a fixed percentage of the grant be reserved for CSOs. They believe that it is the donor that must establish this practice and view it as an obligation. Practices need to be established to change habits and perceptions. The progress in gender equality or environmental issues is evidence of this. This solution will strengthen CSOs and systematically provide funds for their infrastructure, development, and activities. However, once donors withdraw and CSOs find themselves alone with the ministry, the situation could become hugely problematic. CSOs in Eastern Europe and Latin America express their dismay at transitions since they find themselves excluded, with domestic funding exclusively financing the health ministries’ activities.
  • Unintentionally, donor funding enables governments to clear themselves of their responsibility towards CSOs. The Global Fund’s co-financing policy does not compel governments to co-finance civil society activities, but rather to purchase health products and finance state health facilities. This urges ministries to consider community activities as a “whim” of western donors, taking no ownership when donors withdraw. Is the Global Fund ready to request dedicated domestic funding for the activities of CSOs?
  • Additionally, the Global Fund has explored community-level strategies to care for key populations through a rights-based approach. This approach has certainly led to changes in legal frameworks and discussions. It has created awareness among patients and organizations that access to health is a right and an obligation of the state towards its citizens. However, this approach allows health ministries to equate support to CSOs with defending human rights, rather than a strong and effective partnership within the health system.
  • Finally, many CSOs working on the three diseases, particularly those active in HIV, have heavily relied on the Global Fund. They have often become highly dependent on its funding. Just as the Global Fund is seeking partners that can support health systems and complementarity with other donors, it needs to support CSOs to diversify their funding sources, strengthen their structure, communication and advocacy capacity, and their monitoring and evaluation systems. Similarly, the Global Fund must agree to pay management fees to local organizations. This would enable them to sustain some positions that will not only be dedicated to Global Fund-financed activities, but would also be useful for sourcing additional funds and implementing alternative projects. The stronger, more diversified and active CSOs become, the more they will be able to influence policies and ministries to change social and legal frameworks.

These elements should guide reflections on the new strategy, which is expected to include a pillar devoted to community, rights and gender.

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