Ideas to Action:

Independent research for global prosperity

Matthew Greenall

Director of Policy and Programs, International Council of AIDS Service Organizations

In his position as Director of Policy and Programs, Matt oversees the implementation of ICASO’s programs, including the Civil Society Action Team (CSAT), a partnership with 6 regional HIV networks which mobilizes and supports national civil society actors to get involved in Global Fund program governance and implementation; he has also collaborated closely with the Global Fund and other NGOs to ensure civil society perspectives inform the design of the new funding model.  Prior to joining ICASO Matt worked for several years as a consultant, working with UN agencies, NGOs and national AIDS programs on strategic planning, program design and evaluation, with a particular focus on programs with key affected populations.

As other commenters have pointed out, the new ways of working being introduced by the Global Fund must enable it to increase the impact of its investments.  To achieve this, the Fund must build on some of the positive innovations that it has promoted in the past, but it must also take bold measures to address some of the persistent failings of the past.  There are three points that I would like to draw attention to:

  • Building on community systems strengthening.  Since its creation, the Global Fund’s commitment to multi-stakeholder involvement has enabled civil society organizations to have considerable input into the design and implementation of programs.  The introduction of a “Community Systems Strengthening” (CSS) framework helped civil society organizations to better articulate and support interventions that are essential to comprehensive responses to the three diseases – such as health promotion, outreach, home care, referrals, advocacy, and sometimes clinical services.  However, in many countries, these are still seen at best as an optional component and at worst as a threat to formal health systems. The concept of “community systems” and their role within health systems remains under-theorized, and practical understanding of how to mobilize and support community action at scale is limited.  The Global Fund should encourage donors, technical agencies, researchers and recipient countries to build a better understanding of community systems and their position in improving health and supporting health systems.
  • Ensuring “most at risk” or key affected populations are reached by evidence-based, rights-based programs. Although the Global Fund has encouraged applicants to focus on the populations most at risk of the three diseases, and even created a funding pool during Round 10 for applications focused on these populations, results continue to be limited.  The new funding model is likely to incorporate measures aimed at further incentivizing appropriately targeted programs.  However, experience has shown that once grants are agreed there is considerable attrition and disappointing performance in programmes with these groups, most commonly in HIV grants that should reach men who have sex with men, transgender people, sex workers, and people who use drugs. Furthermore, reflecting how these populations are treated in many countries, programs are often of poor quality and fail to tackle underlying causes of vulnerability.  While the Fund should make every effort to encourage national programs to reach key affected populations with effective, rights-based programs, it must accept that often the only way of reaching them is to make it easier for community organizations and networks representing these populations to access funding directly, even if this means bypassing CCMs.  Conditions for non-CCM applicants, and the challenges involved in designing and implementing regional (multi country) programs make it virtually impossible for these groups to access funding directly.  The Fund must develop more realistic ways of funding essential, high-impact programs that are neglected or poorly delivered in CCM developed proposals.
  • Transforming country ownership. The Global Fund has championed the principle of country ownership, manifested in particular through the CCM model.  There is some scepticism about country ownership, as it is sometimes seen as a barrier to effective investment.  However, it is not the concept but the approach to country ownership that needs to be improved.  Although much has been done to make CCMs more representative, and to build their capacity to provide effective oversight of programs, in most countries community representatives struggle to influence the agenda.  Tellingly, CCM oversight focuses on abstract measures, and community representatives are expected to comment on budget flows, performance indicators, and compliance, rather than on the things that they are most qualified to talk about, such as regular feedback and input from communities on how programs are affecting them, problems faced in accessing services, and the extent to which human rights are being protected. The Global Fund, with other donors and technical partners, must adapt its approach to country ownership by placing greater emphasis on understanding, routinely, how programs are working for the communities they aim to support. 

The challenge for the Global Fund in this new phase is to stay true to its founding principles – accountability, multi-stakeholder engagement, and country ownership – by building on its successes and by transforming its approach where it has been shown to be ineffective. The Global Fund cannot achieve this if it does not maintain its unique identity and structure.