On July 16th, W4GF hosted it’s fourth webinar of the year on Community Based Monitoring (CBM). The webinar provided an opportunity for 19 W4GF Advocates and partners to engage with the Global Fund Secretariat to share CBM best practices.
It is essential that women remain engaged in the implementation beyond funding requests submitted to the Global Fund. A key way to do this is to monitor that the funds advocated for reach the right communities, respect human rights and benefit women and adolescent girls and young women (AGYW) in all their diversity. CBM can help to capture the lived realities of communities, ensures services are working as intended, maximises complementarities and ensures greater impact for people and communities. CBM helps us to make the case that we are investing in the right programmes that address inequities and that promote human rights and gender equality.
Community monitoring refers to a form of public oversight where communities, whether directly or indirectly, demand greater accountability from policy makers and providers in relation to the delivery of public services. (InScale Community Monitoring in a Volunteer Health Worker Setting: A Review of the Literature, March 2011 available here) The data that communities can collect (Qualitative) is different and can complement the data that governments and Principle Recipients (PRs) collect (Quantitative).
- Quantitative data collection (used by Global Fund implementing countries) is designed to collect cold, hard facts and numbers. Countries are now encouraged to report data that is desegregated by age and sex. Quantitative data are structured and statistical and speaks to the “what” and counts numbers of people for example how many people are accessing services and treatment.
- Qualitative data collection provides information that seeks to describe a topic and answers the why and how) more than measure it. Think of impressions, opinions, and views. Qualitative data seek to delve deep into the topic at hand, to gain information about people’s motivations, thinking, and attitudes. This brings a depth of understanding to questions, but it also takes longer for the results to be analysed.
Whilst both approaches are important in measuring and tracking change CBM offers a more holistic means necessary for tracking change particularly at a national level.
- Gavin Reid, Technical Advisor on Community Responses and Systems Global Fund Secretariat
- Rene Banger, Program and Data Coordinator Global Fund Secretariat
Key points made by Global Fund
The Global Fund Board’s commitment to CBM is evident through its inclusion in The Global Fund 2017-2022 Strategy. Building Resilience and Sustainable Systems for Health (RSSH) is a Strategic Objectives of the Global Fund Strategy. A sub-objective of this is “Community Responses and Systems” which is one of seven key interventions and includes: CBM to improve accessibility, responsiveness and quality of services; Community-led advocacy; Social mobilisation, building community linkages, collaboration and coordination between communities and other health actors; and Institutional capacity building, planning and leadership development.
The Global Fund sees community responses as an array of responses closely linked with the formal health system to fully self-directed. Some types of community response are increasingly accepted by ministries (left hand side) whilst others (right hand side) are not necessarily recognised as health-related interventions.
They are not always incorporated in national health or disease plans. Indeed, at times, they may be seen by the health sector as antagonistic, because they can challenge what national programs are doing or not doing. This includes community based monitoring and feedback mechanisms that help improve quality and responsiveness of services. Nonetheless, there is growing recognition that these responses make an important contribution to better health
“Top-down” approaches to monitoring focus on macro level targets and financial accountability and are inadequate to highlight local realities in communities and remain slow in responding to needs of individuals within those communities. CBM extracts essential information which quantitative monitoring cannot. It determines the quality and suitability of services delivered with the consideration of local realities and highlights barriers to accessing services.
The Global Fund’s working definition of CBM is “A process by which service users or local communities gather and use information on service provision or information on local conditions impacting on effective service provision, in order to improve the responsiveness, equity and quality of services and hold service providers to account. CBM can be general (e.g. range of health services at community level), or disease specific (e.g. monitoring availability of long-lasting insecticide-treated nets), or even sub-programme specific (e.g. quality of specific service for adolescent girls).”
(Slide 8): Four models of community monitoring (identified by the London School of Economics):
- Downward accountability (e.g. complaint-handling or suggestion systems)
- Citizens as Service Delivery Watchdogs (e.g. reporting stock-outs of essential drugs). Examples include International Treatment Preparedness Coalition (ITPC) West Africa Treatment observatories to gather information around the treatment cascade for key and vulnerable populations and Y+ where young people developed a scorecard and shared results with health care providers in a non-threatening way).
- Local Health Governance Mechanisms (e.g. Local Health Councils).
- Social Audit (e.g. comprehensive approach, incorporating a variety of tools and processes)
See slide 10 and 11 for key principles related to CBM.
Under the Community Rights and Gender Strategic Initiative (CRG SI) organisations are eligible to apply for technical assistance (TA) for CBM. The TA support should be intended for holding consultations on sharing best practices for community monitoring, strategy development for community monitoring looking at various feedback mechanisms for CBM. Capacity building, advocacy and implementation of activities are not eligible for TA where CBM is concerned
Experience from Community Partners
(Slide 8) The ITPC’s CBM tool is reliant on monitoring by community members in West Africa who monitor barriers to accessing treatment with a focus on key and vulnerable populations by collecting both qualitative and quantitative data. Information is gathered and validated nationally at country level and then passed on regionally to the regional treatment observatories. The data generated informs advocacy by influencing regional and national policymakers.
Alain Manouan (ITPC) spoke to the Community Treatment Observatory (CTO) includes:
- Networks of people living with HIV collect and analyse qualitative and quantitative data on barriers along HIV treatment cascade, particularly for key and vulnerable populations
- Alerts inform dialogue with service providers to increase access to ART incl. paediatric ART, VL testing in 11 West African countries
- Engage and influence national and regional policy makers (through regional community treatment Observatory).
Key challenges include: capacity of the data collectors who must be well trained to understand the process and able to make the first analysis before it is uploaded to the national database. The countries are grouped into three categories: 1) those working in capital cities; 2) those in district levels; and 3) national CTOs who collect data in the region. This has overcome challenges of operating in 11 countries in different languages.
Cedrick Nininahazwe – Young Global Network of People Living with HIV (Y+)
Y+ provided insight into a community tool devised for young people living with HIV to support their engagement and to communicate their needs to health providers. Community Adolescent Treatment Supporters (CATS) are used to mobilise young people living with HIV and encourage them to complete the scorecard annually. The youth Scorecard, was eventually endorsed by government services providers who see this as mutually beneficial for both the service providers and the young people living with HIV. The first results of the Y+ Scorecard will be shared in September. Cedrick spoke to the key challenges around using the scorecard that was developed which mostly included supporting young people to use this and to validate the finding. The tool itself aims to strengthen the relationship between health providers and young people living with HIV. The demands generated by the scorecard were presented to health providers as a way to strengthen services in a non- confrontational and threatening way.
CISMAT-SL shared benefits and challenges in CBM of Tuberculosis health services in Sierra Leone. In Sierra Leone community monitoring contributes to active case finding and strengthening service delivery for TB. The data is gathered and concerns and cases are escalated to the NTP. Results are utilised to inform advocacy to address stigma and discrimination and address barriers to accessing treatment. Abdulai spoke to CBM and Feedback (CBMF) around TB programming. Key challenges include:
- Inadequate technical support on data collection – people need to be trained on how to do this
- Capacity to analyse results and information and turning this into recommendations
- CBM can be expensive and requires good investment which is lacking
- Low investment for CBM
- Communicating and dissemination of the results effectively as recommendations that can be used by the NLTCP
- Delays in sending CBM report at HQ.
Slides which provide more details are available here.
Two other examples presented:
Sibu Malambo- Zambian Youth Platform (ZYP) has been developing an Accountability Framework through CRG TA. ZYP has, from the outset, been very smart about involving the CCM and PRs to ensure that CBM is seen as an initiative that will benefit everyone. ZYP has built momentum and trust so that this is not seen as a threat but seen as something that can enhance programmes implemented with Global Fund resources. ZYP in Zambia is striving to highlight the legitimacy of CBM on the CCM. It is also important to work with other partners such as PEPFAR who often have resources and are also trying to monitor programmes.
India HIV AIDS Alliance also developed a scorecard under a CDC supported LCI Nirantar program. They developed 72 scorecards and engaged 1526 key population community members and 466 health care providers. The best part of the process is the INTERFACE MEETING, in which KPs, HCPs, government stakeholders and policy makers discuss and develop a common action plan. They also developed a dashboard (using tableau software), on which scores are monitored and progress on action points completed is tracked by communities at local level.
Discussion and Questions
How are CBMs engaging with governments for issues outside the prevue of health providers? And What should be done where there is no political will?
A: There are examples of where governments in certain countries were distrustful of the observatory and questioned the credibility of the data and the methodology. Over time and by engaging early on and building support on methodology and strengthening relationships, CBM can be viewed as an intervention that will benefit both governments and community members.
CISMAT-SL shared that the work that they are doing is supported by the Government and it is important to have this. Before implementing CBMF CISMAT-SL conducted stakeholder meetings do ensure everyone was onboard. A letter was then sent to all health facilities informing them that CISMAT-SL would be conducing this work and this gave them credibility.
There are many tools for people living with HIV and young people living with HIV. If these tools are available to everyone how can we ensure consistency? Is there guidance on how to use the tools and to ensure consistency? And when a programme finished how do we access these tools?
A: ITPC Response – The data collection guideline developed by the ITPC ensures uniformity in data collection and analysis at a regional level. A training is also arranged for those who will conduct the work. The tools are accessible through ITPC but it is also accessible through the Global Fund as this is a shared tool – it is a work in progress. Data collection is currently being piloted in Zimbabwe using tablets whilst in West Africa (due to the numbers of countries and the budget) the data collected is paper-based.
Youth + Response: Whilst the tool was developed by Y+ it is up to them to introduce the tool in health facilities. The tools are not rigid but help to identify and highlight the needs of people living with HIV. Adaptation can be made in each implementing community network who takes ownership of the tool and can expand to different stakeholders.
It was great to see Abdulai’s presentation related to CBM and TB. This is so important and not happening enough! Are there plans to create more awareness/build capacity for CBM as it cannot be part TA requests?
A: The Global Fund Secretariat is making efforts to create understanding around CBM. Awareness still remains is low and there is a need to conduct ongoing awareness. There is some CBM work happening in HIV, less in TB and even less around Malaria. Recently the Global Fund hosted a workshop to share in country experiences in Francophone West and Central Africa. The Global Fund will disseminate the workshop outcomes in English and in French. The Global Fund is also engaging with country teams around common needs. EANNASO is in the process of developing a tool for CBM. The Global Fund acknowledged the need to increasing awareness around CBM and amplifying use within CCMs. The Global Fund is also eager to learn from civil society.
Key Discussion Outcomes
- It’s important for communities (especially those who are marginalised, key and vulnerable) to be engaged so that we are viewed as partners credible partners and not just beneficiaries.
- There is a need for us to share and exchange the various tools that we are working on and that are available.
- Community Based Monitoring is ESSENTIAL and should also be included in funding requests to the Global Fund. It’s important for the Global Fund Secretariat to continue to educate PRs and the CCM to understand CBM.
- W4GF to arrange a follow up webinar for those working on various tools for CBM to encourage information exchange and create a platform for networking.
This webinar had 19 participants: Abdulai Sesay, Alain Manouan, Albertina Nyatsi, Alexandra Stanciu, Claris Ojwang, Cedric Ninninahazwe, Gemma Oberth, India HIV Alliance, Jill Gay, Mouangue Zanenkone Menkande, Muneeb, Nonna Turursbekova, Ronnie Jere, Sibu Malambo, Tahira. Global Fund Secretariat representatives included: Gavin Reid and Rene Bangert. The W4GF Secretariat was represented by Sophie Dilmitis and Matipa Ndoro.