PEPFAR and The Global Fund approaches to Civil Society TA

Ambassador Goosby, speaking at the April 2011 Civil Society Hearing of the United Nations in New York, referred to the civil society and community implementers being ‘more effective’ and ‘better placed’ for the delivery of services. As the Global AIDS Coordinator of the US Government PEPFAR he had taken on the programme that had run since 2005 called the New Partners Initiative. The New Partners Initiative (NPI) made its first awards in 2006 to 23 prime recipients. The second round (mid 2008) and third round of awards (early 2009) brought the number of prime recipients to 53 organisations. Each received three year awards with annual values of US$500,000 to US$1 million. Many of the prime organisations reflected the original announcement by President Bush on WAD December 1, 2005:

“This new initiative will establish a competitive grants process for new partners, including faith- and community-based organizations, with the desire and ability to help implement PEPFAR, but who have little or no experience in working with the United States government. By identifying and supporting the organizations that provide much of the health care in the developing world, PEPFAR resources will reach more people, more effectively”.

The prime organisations all had pre-identified sub partners or subsidiary implementation sites and across round 2 and round 3 awards, 30 primes encompass over 150 organisations, some with faith-based backgrounds and all with community-level permanent sites. Since late 2008 a team of Ugandans, an Ethiopian and a long term (British) resident of Uganda have planned and delivered Technical Assistance (TA) to 10 of these New Partner Initiative (NPI) prime recipients in sub-Saharan Africa.  A good example of local TA providers helping indigenous organisations.

Defining Non-Governmental, Community Based and the role of Faith
Within the US Government funding history, in-country organisations which are not staffed by government employees (ie Non-Governmental Organisations) have been part of the programme implementation on a quite narrowly defined basis - usually with a US contractor being the prime. More recently, the Private For Profit sector is recognised as having a role in increasing service access and sharing bulk cost savings in drugs and commodity distribution.

The term NGO has been retained by the start-up organisations that were at the forefront in a country in the late 80s and early 90s but which now are national if not multi-country in their work. They now have similar organisational structures of administration - and overheads and detachment from the grassroots – that government and the large development contractors have. They are the big names in their countries, in many cases the leading mentors and setters off standards at a technical programme level – but they are not primarily builders of organisational skills nor managers of finances. When they do get such a role, the rapid recruitment exercise they undergo to take on staff with these skills is quite noticeable. Their relationship ‘with the community’ and being geographically ‘local’ to the affected populations becomes more strained as they spend more time on policy and national advocacy – both essential roles, but not to be at the expense of community delivery of HIV and health services.

The ‘narrowly defined’ basis of involvement with CSO to date has been characterised by an international prime contractor, or a large national level NGO, being awarded additional funds beyond what it’s staff and administration require and having a contract obligation to ‘work in partnership with community organisations, to scale up services and trickle-down the skills’. This has usually led to all financial management capacity being retained at the level of the capital-city prime contractor and the community CBO being used/ exploited for the short term impact. Little capacity development or community systems strengthening is achieved – and where it is, it is through the greater effort by the CBO than being the intention in the design.

The support to the lower level implementer tends to be solely related to delivery of a good counselling session, distribution of the net or water kit or visiting 20 households per person for adherence and then, importantly, filling out the M&E forms for the prime to collate and report upon. Through this model, the NGO, actually a national or multi-country quasi-commercial organisation, has claimed that it is community based or ‘local and indigenous’ and yet is detached in socio-economic scale and hundreds of miles from the intended beneficiary communities. NPI has been a chance to develop prime recipients closer to the beneficiaries.

Under the New Partners Initiative, the ‘community-based’ has been more fairly defined. The organisation’s that the TA to NPI team worked with included: a clinic in Ugenya with community outreach in Western Kenya; a treatment site with intensive-care clinic adjoining a Baptist church in South Africa’s Eastern Cape; a growing clinic situated in Fonds des Blancs, five hours west of Port au Prince, Haiti. These organisations do include some nationwide secretariats – in two instances the nation’s inter-religious council – but these are channelling most of the funds to their permanent members dispersed throughout Ethiopia, Kenya, Rwanda and Tanzania.

Also identified was a variation on ‘faith-based’. Several employees at the sites, sites where there is no morning prayer or active mission, cite their personal faith as a key motivational factor that supports their work and their colleagues in times of low funding or challenging patients. Some prevention oriented CBO are overtly faith-based in their justification for delaying sexual debut – the Eastern Cape Baptists are more simply driven to serve their community and meet in their home groups and worship to re-strengthen each other.

Feedback from civil society organisations on past ‘TA’ and capacity building
The model of funding used by The Global Fund (TGF) - national Prime Recipients and then Sub-Recipients or Sub-Sub-Recipients - was probably derived from the historical donor funding flows and the desire to avoid more parallel structures. In that sense, the early rounds of TGF followed the similar TA model to European and US Governments. Dated January 2010, the International HIV/ AIDS Alliance with UNAIDS and the Civil Society Action Team issued a report analysing technical support to civil society organisations that had been TGF grantees. The report was at http://www.csactionteam.org/?file=128 now https://www.scribd.com/document/84060295/Analysis-of-Technical-Assistance-to-Civil-Society-Recipients-of-Global-Fund-Grants 

It is very interesting as it supports the view developed from the TA to NPI work that CSO want and deserve more than just ‘program’ support. They want to work better with their volunteers, more openly coordinate with local government and other partners and be heard as they share their successful implementation of service delivery. The respondents, both CSO and their current range of TA providers mentioned that a carefully planned mix of short term and medium or even long-term mentoring support is often appropriate as the living organisation learns and utilises new skills. They wanted to look beyond the current brief interventions and to build collaborative skills, internal management structures and cooperation with government.

Key features of Technical Assistance to PEPFAR’s New Partners Initiative
The key difference of TA to NPI has been that the implementing sites are pre-existing entities, with established reputations, staff, systems and characters. They are not staffed by government (defining them as NGO) but are also physically and emotionally community based. These are not coerced to undertake the activity as they applied for the funds to serve the needs of their beneficiaries, their neighbours. The funding from PEPFAR and the TA of the NPI project has been additional to their existing programmes, often becoming complementary towards comprehensive services that the community needs. These CBO existed before NPI, grew with NPI, and will be stronger as they continue to serve their communities after NPI. The TA they have received was also to help them post-NPI.

The TA to NPI had three channels of support – which seem to also be those sought by the respondents to the CSAT/ TGF report. Discussions have been held with UNAIDS and TGF on working together as they concede their capabilities for TA are generally short-term due to funding limitations. The three channels to which TA to NPI work has been categorised are:

     1. very broad, yet in-depth organisational development encompassing the whole CBO and its financial, governance, volunteer relations, group-working and administrative systems for internal management and program management and monitoring;

    2. technical programme support that is country compliant and locally appropriate with emphasis on the client and what happens to them before the care and support intervention or after the counselling session;

    3. strong collaboration with government, beneficiaries and stakeholders including other implementers or micro-level organisations and groups regardless of their funding sources and with the intention of supporting a self-sustaining network of service provision and community feedback for emerging health and economic situations.

Regional teams comprising a small core with continuity of support: the TA-NPI model
The CSAT observations on the ideal technical support included:

    · local consultants/ support people with sufficient knowledge of the situation and culture of the community are highly preferable to ‘parachute-in’ consultants;

    · when the information or technical support is relevant to multiple countries or communities, a regional support with multi-country insights for the application of the support is helpful (eg learning TGF grant rules or procurement guidelines)

    · organisational support – meaning finance, staff management and administration – was seen to have contributory benefits to the technical programme implementation.

    · whether planned through budget allocations, the pre-award expectations of the CBO for the TA they would need was usually understated or miss-defined as it was not until they began work that they could consider what they really needed; and didn’t know.

    · a continuing range of support that helped establish need and recognised those needs and the ability to recognise their importance would develop over time within the CBO.

TA-NPI formed a core team of eight staff - “the Specialists” - based in Kampala, East Africa. None of these had worked for a US contractor before and being East Africans by passport, schooling and upbringing, they represent an example of the ‘local skills’ and ‘local capacity’ that is so often sought. Just as UNAIDS uses regional citizens for the TSF, so TA to NPI proved high quality services and support, including finance, technical and collaboration skills with government could be staffed and delivered with minimal non-African staffing or technical input. The work was delivered in seven sub-Saharan countries from a base in Uganda.

The staff and the costs related to working with the CBO were funded by PEPFAR and therefore the decision by CBO to draw on the TA is not limited by their budgets or a trade-off to operational costs. In addition to the Specialists – financial management, human resources, donor compliance, quality and program performance, M&E – there are options for short-term TA on specialist topics, multi-week direct support staff and NPI Advisors. These Advisors live with the CBO as counterparts or mentors to a member of management or a programme team to help the CBO through its changes and adoption of strengthened systems and programme approaches. The specialists, their work and the views of the CBO are at http://tanpi.jsi.com

The availability of the regional team, serving seven countries in East and Southern Africa, reduces duplication such as one M&E staff member per country, and provides scope for inter-country sharing and learning for the CBO. This pooling of experiences and resolutions to challenges across countries is a true example of peer level ‘south-south’ support. But, more so, the implementers of TA to NPI are either of the region (Ugandans, Ethiopians, Kenyans) or include long-term residents with over 10 years ‘real world’ experience of NGO in the region. The in-country US Mission staff allocated to a funded implementer (AOTR/ Activity Manager) do not have the breadth of experience of such a team, nor the time for this level of support.

Even further into the characteristics of the support providers to the CBO, the members of the TA to NPI team combine their personal experience of managing or working with a community level NGO as well as the professional experience of mentoring and coaching others through their roles in those organisations. In contrast to the quasi-establishment ‘NGO’ that are primarily service delivery and then take on organisational development or sustainable management and networking, TA to NPI is focussed on strengthening the capabilities of faith-based and community organisations to serve the needs of their communities in the long-term.

Observations for the Faith Based and Community Initiatives and GHI
The NPI, being funded from the original PEPFAR, led to awards for HIV service delivery. In the past five years, the organisations that received the NPI funds and the TA-NPI support have evolved as they had other funding for education or rural development programmes, or were already healthcare facilities with maternal health and fever management services.

This means that the application of TA to CBO already has years of examples through NPI with faith-based organisations, organisations that are community-founded and managed, and organisations that work in broader health and rural development sectors. For the donors that could use faith based and community initiatives as their preferred implementers, and as the Global Fund and the US GHI looks to sustainable rather than emergency responses, more services will be delivered through CBO and FBO as well as some remaining with the national mega-NGO. There are already local TA strong enough to provide this support in the region.