COMMUNITYSYSTEMSSTRENGTHENINGFRAMEWORK

MAY2010

ACRONYMS&ABBREVIATIONS
ACSM AIDS CBO CSO CSS DOTS FBO GForGFATM GHI HIV HSS M&E MDGs NGO OGAC PMTCT SDA TB TWG UNAIDS UNDP UNGASS UNICEF US USAID WHO Advocacy,communicationandsocialmobilisation Acquiredimmunedeficiencysyndrome Communitybasedorganisation Civilsocietyorganisation Communitysystemsstrengthening Directlyobservedtreatment,shortcourse Faithbasedorganisation GlobalFundtofightAIDS,TuberculosisandMalaria Globalhealthinitiatives Humanimmunodeficiencyvirus Healthsystemsstrengthening Monitoringandevaluation MillenniumDevelopmentGoals Nongovernmental organisation OfficeoftheGlobalAIDSCoordinator(USgovernment) Preventionofmothertochildtransmission(ofHIV) Servicedeliveryarea Tuberculosis TechnicalWorkingGroup JointUnitedNationsProgramme onHIV/AIDS UnitedNationsDevelopmentProgramme UnitedNationsGlobalAssemblySpecialSessiononAIDS UnitedNationsChildrensFund UnitedStatesofAmerica UnitedStatesAgencyforInternationalDevelopment WorldHealthOrganisation

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CONTENTS
Acronyms&abbreviations Foreword ExecutiveSummary 1.CommunitySystemsStrengtheningaframework Keytermsusedintheframework WhatisthepurposeoftheCSSframework? Whoisthisframeworkfor? 2.Strengtheningcommunitysystemstocontributetohealthoutcomes Whatiscommunitysystemsstrengthening? Whatneedsstrengthening? Whathealthrelatedactivities&servicesdocommunitysystemsdeliver? Communitysystemsandhealthsystems linkedandcomplementary 3.Thecorecomponentsofafunctionalcommunitysystem Corecomponent1:Enablingenvironmentsandadvocacy SDA1:Monitoringanddocumentationofcommunityandgovernmentinterventions SDA:Advocacy,communicationandsocialmobilisation Corecomponent2:Communitynetworks,linkages,partnershipsandcoordination SDA3:Advocacy,Communicationandsocialmobilisation Corecomponent3:Resourcesandcapacitybuilding 3.1Humanresources: SDA4:Skillsbuildingforservicedelivery,advocacyandleadership 3.2Financialresources SDA5:Financialresources 3.3Materialresourcesinfrastructure,information,essentialcommodities SDA6:Materialresourcesinfrastructure,information,essentialcommodities(including medicalproductsandtechnologies) Corecomponent4:Communityactivitiesandservices SDA7:Serviceavailability,useandquality Corecomponent5:Organisationalandleadershipstrengthening SDA8:Management,accountabilityandleadership Corecomponent6:Monitoring&evaluationandplanning SDA9:Monitoring&evaluation,evidencebuilding SDA10:Strategicandoperationalplanning 4.CommunitysystemsstrengtheninginthecontextoftheGlobalFund 5.AsystematicapproachfordevelopingCSSinterventions,includingmonitoring&evaluation 6.IndicatorsforCSS 6.1DevelopmentofCSSindicators 6.2OverviewofrecommendedCSS indicators 6.3DetailedCSSindicatordefinitions

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i iv vi 1 1 2 6 7 7 7 10 12 15 16 17 18 19 19 20 20 21 22 22 23 24 25 26 27 27 28 28 31 33 34 38 38 41 45

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7.Usefulresourcesandreferences a) Sourcesofsupportandtechnicalassistance b) ResourcesreferencedintheCSSFramework

73 73 73

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FOREWORD
Theconceptofcommunityinvolvementinimprovinghealthoutcomesisnotanewone.Ithasitsrootsinthe action that communities have always taken to protect and support their members. Modern approaches to communityhealthcarearereflectedintheAlmaAtadeclarationof19781,themorerecentworkofWHOon thesocialdeterminantsofhealth2andtherelaunchoftheprimaryhealthcareconceptin20083.Theselaid thefoundationsformuchoftheworkthathasbeendone,highlightingtheroleofcommunitiesinincreasing the reach and impact of health systems, for example in TB, malaria and HIV care and prevention.4 5 6It has becomeincreasinglyclearthatcommunitysupportforhealthandsocialwelfarehasuniqueadvantagesinits close connections with communities, its ability to communicate through peoples own culture and language and to articulate the needs of communities, and its ability to mobilise the many resources that community memberscanbringtotheprocessesofpolicyanddecisionmakingandtoservicedelivery. Further progress is now needed to bring community actors and systems into full partnership with national healthandsocialwelfaresystemsandinparticulartoensurethattheirworkforhealthisbetterunderstood andproperlyfunded.Achievingthisgoalisvitalformakingprogresstowardsthegoalsofuniversalaccessto health care and realising the rights of everyone to achieve the highest attainable standards of health, no matter who they are or where they live. The Community Systems Strengthening (CSS) Framework is a contributiontowardsthis. The Global Fund to fight AIDS, Tuberculosis and Malaria developed the Framework in collaboration with a rangeofstakeholders,supportedbyaTechnicalWorkingGroup(TWG)thatincluded:UNAIDS,WHO,UNICEF, World Bank, MEASURE Evaluation, Coalition of the Asia Pacific Regional Networks on HIV/AIDS (7 Sisters), InternationalHIV/AIDSAlliance,USAIDOfficeofHIV/AIDS,andUSOfficeoftheGlobalAIDSCoordinator,UNDP Burkina Faso, Ministry of Health & Social Welfare Tanzania, Carolyn Green as an independent consultant and Global Fund staff. Finalisation of the draft was supported by a Harmonisation workshop which brought together experts and consultants on monitoring and evaluation as well as an extensive international consultation with civil society, using an online questionnaire, interviews and a twoday meeting with key informants.7 TheFrameworkisprimarilyaimedatstrengtheningcivilsocietyengagementwiththeGlobalFund,withafocus on HIV, tuberculosis and malaria. However, a broad health development approach has been taken and the
1

DeclarationofAlmaAtaInternationalconferenceonprimaryhealthcare1978 http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf WHOsocialdeterminantsofhealthhttp://www.who.int/hia/evidence/doh/en/index.html TheWorldHealthReport2008primaryhealthcarehttp://www.who.int/whr/2008/en/index.html

2 3 4

Communityinvolvementintuberculosiscareandprevention;WHO2008 http://www.stoptb.org/resource_center/assets/documents/Community%20involvement%20in%20TB%20care%20and%20 prevention.pdf

5

Communityinvolvementinrollingbackmalaria;RollBackMalaria/WHO2002 http://www.rollbackmalaria.org/cmc_upload/0/000/016/247/community_involvement.pdf Partnershipwork:thehealthservicecommunityinterfacefortheprevention,careandtreatmentofHIV/AIDS;WHO2002 http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf

CommunitySystemsStrengtheningCivilSocietyConsultation;InternationalHIV/AIDSAlliance2010/ICASO http://www.aidsalliance.org/Pagedetails.aspx?id=407

Framework will therefore also be useful for working on other health challenges and supporting community engagementinimprovinghealthoutcomes.

EXECUTIVESUMMARY
The goal of Community systems strengthening (CSS) is to develop the roles of key affected populations and communities, community organisations and networks, and public or private sector actors that work in partnershipwithcivilsocietyatcommunitylevel,inthedesign,delivery,monitoringandevaluationofservices andactivitiesaimedatimprovinghealthoutcomes.Ithasastrongfocusoncapacitybuildingandonhuman and financial resources, with the aim of enabling communities and community actors to play a full and effectiverolealongsidehealthandsocialwelfaresystems. The Community Systems Strengthening Framework has been developed in the light of experience and in recognition of the need for increased clarity and understanding of CSS. It is intended to facilitate increased funding and technical support for CSS, particularly (but not only) for community based organisations and networks.TheFrameworkdefinestheterminologyofCSSanddiscussesthewaysinwhichcommunitysystems contribute to improving health outcomes. It provides a systematic approachfor understanding theessential components of community systems and for the design, implementation, monitoring and evaluation of interventionstostrengthenthesecomponents.

WHYISCOMMUNITYSYSTEMSSTRENGTHENINGIMPORTANTFORHEALTH?
Communityorganisationsandnetworkshaveuniqueabilitytointeractwithaffectedcommunities, reactquicklytocommunityneedsandissuesandengagewithaffectedandvulnerablegroups.Theyprovide direct services to communities and advocate for improved programmeming and policy environments. This enables them to build a communitys contribution to health, and to influence the development, reach,implementationandoversightofpublicsystemsandpolicies. Communitysystemsstrengtheninginitiativeshavetheaimofachievingimprovedoutcomesforinterventions todealwithmajorhealthchallengessuchasHIV,tuberculosis,malariaandmanyothers.Animprovementin health outcomes can be greatly enhanced through mobilization of key affected populations and community networks and an emphasis on strengthening community based and community led systems for: prevention, treatment, care and support; advocacy; and development of an enabling and responsive environment. In order to have real impact on health outcomes, however, community organisations and actors must have effectiveandsustainablesystemsinplacetosupporttheiractivitiesandservices.Thisincludesastrongfocus oncapacitybuilding,humanandfinancialresources,withtheaimofenablingcommunityactorstoplayafull andeffectiverolealongsidethehealth,socialwelfare,legalandpoliticalsystems.CSSisameanstoprioritise adequateandsustainablefundingforspecificoperationalactivitiesandservicesand,crucially,corefundingto ensureorganisationalstabilityasaplatformforoperationsandfornetworking,partnershipandcoordination withothers.

IMPLEMENTINGCOMMUNITYSYSYTEMSSTRENGTHENING
InordertotakeasystematicapproachtoCSS,theFrameworkfocusesonthecorecomponentsofcommunity systems,allofwhichareconsideredtobeessentialforcreatingfunctional,effectivecommunitysystemsand enablingcommunityorganisationsandactorstofulfiltheirroleofcontributingtohealthoutcomes: 1. Enablingenvironmentsandadvocacyincludingcommunityengagementandadvocacyforimproving thepolicy,legalandgovernanceenvironments,andaffectingthesocialdeterminantsofhealth.

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2. 3.

Communitynetworks,linkages,partnershipsandcoordinationenablingeffectiveactivities,service deliveryandadvocacy,maximisingresourcesandimpacts,andcoordinated,collaborativeworking. Resourcesandcapacitybuildingincludinghumanresourceswithappropriatepersonal,technical& organisationalcapacities,financing(includingoperationalandcorefunding)andmaterialresources (infrastructure,informationandessentialmedical&othercommodities&technologies). Communityactivitiesandservicedeliveryaccessibletoallwhoneedthem,evidenceinformedand basedoncommunityassessmentofresourcesandneeds. Organisationalandleadershipstrengtheningincludingmanagement,accountabilityandleadershipfor organisationsandcommunitysystems. Monitoring & evaluation and planning including M&E systems, situation assessment, evidence buildingandresearch,learning,planningandknowledgemanagement.

4. 5. 6.

ForeachofthecorecomponentsdescribedintheFramework,potentialCSSinterventionsandactivitiesare grouped within specific service delivery areas (SDAs), with a rationale and a nonexclusive list of activity examplesforeachoftheseSDAs. MonitoringandevaluationforCSSalsorequiresasystematicapproach.TheFrameworkprovidesguidanceon the steps required to build or strengthen a system for CSS interventions. It includes a number of recommendedCSSindicatorsforeachSDAwithdetaileddefinitionsforeachofthem.Theseindicatorshave beendevelopedinconsultationwithtechnicalpartnersandcivilsocietyrepresentatives.Theyaredesignedto enablemeasurementofprogressincommunitysystemsstrengtheningovertime. InthecontextoftheGlobalFund,applicantsareencouragedtoconsiderCSSasanintegralpartofassessments ofdiseaseprogrammesandhealthsystems,ensuringthattheyidentifythoseareaswherefullinvolvementof thecommunityisneededtoimprovethescopeandqualityofservicesdelivery,particularlyforthosehardest to reach. A brief description is provided of how CSS can be included within Global Fund proposals; further guidanceistobefoundwithintheGlobalFundProposalFormandGuidelinesrelevanttoeachfundinground, startingwithRound10. ThisfirsteditionoftheCSSFrameworkisamajorstepinthedirectionofenhancingcommunityengagement andeffectivenessinimprovinghealthoutcomesandincreasingtheircollaborationwith,andinfluenceon,the publicandprivatesectorsinmovingtowardsthisgoal.ExperiencewithimplementationoftheFrameworkwill helptofurtherimprovethedefinitionandscopeofCSS,whichwillcontinuetoberevisitedandmodifiedinthe lightoflessonslearnedinawidevarietyofcommunities,countriesandcontexts.

1. COMMUNITYSYSTEMSSTRENGTHENINGAFRAMEWORK
KEYTERMSUSEDINTHEFRAMEWORK
This Framework is intended to bring clarity and greater understanding on the topic of community systems strengthening.ItisthereforeessentialfirsttoclarifytheterminologyofCSS.Manyofthetermsemployedin thisframeworkarealreadyincommonusebuttheirmeaningsinvariouscontextsarevariableandsometimes imprecise.ThefollowingdefinitionsaretheonesthathavebeenadoptedforusethroughouttheFramework. Community systems are communityled structures and mechanisms used by communities through which community members and community based organisations and groups interact, coordinate and deliver their responsestothechallengesandneedsaffectingtheircommunities.Manycommunitysystemsaresmallscale and/or informal. Others are more extensive they may be networked between several organisations and involvevarioussubsystems.Forexample,alargecareandsupportsystemmayhavedistinctsubsystemsfor comprehensive homebased care, providing nutritional support, counselling, advocacy, legal support, and referralsforaccesstoservicesandfollowup. Communitysystemsstrengthening(CSS)isanapproachthatpromotesthedevelopmentofinformed,capable and coordinated communities and community based organisations, groups and structures. CSS involves a broadrangeofcommunityactors,enablingthemtocontributeasequalpartnersalongsideotheractorstothe longterm sustainability of health and other interventions at community level, including an enabling and responsiveenvironmentinwhichthesecontributionscanbeeffective.ThegoalofCSSistoachieveimproved healthoutcomesbydevelopingtheroleofkeyaffectedpopulationsandcommunitiesandofcommunitybased organisationsinthedesign,delivery,monitoringandevaluationofservicesandactivitiesrelatedtoprevention, treatment, care and support of people affected by HIV, tuberculosis, malaria and other major health challenges. Communityisawidelyusedtermthathasnosingleorfixeddefinition.Broadly,communitiesareformedby peoplewhoareconnectedtoeachotherindistinctandvariedways.Communitiesarediverseanddynamic, andonepersonmaybepartofmorethanonecommunity.Communitymembersmaybeconnectedbyliving in the same area or by shared experiences, health and other challenges, living situations, culture, religion, identityorvalues. Key affected populations, people or communities are those who are most vulnerable to and affected by conditionssuchasmalaria,tuberculosisandHIVandarethemostoftenmarginalisedandhavethegreatest difficulty in achieving their rights to health. This includes children, youth and adults affected by specific diseases such as HIV, tuberculosis or malaria; women and girls; men who have sex with men; injecting and other drug users; sex workers; people living in poverty; street children and outofschool youth; prisoners; migrants and migrant labourers; people in conflict and postconflict situations; refugees and displaced persons.8 Communitybasedorganisations(CBOs)aregenerallythoseorganisationsthathavearisenwithinacommunity in response to particular needs or challenges and are locally organised by community members. Non governmentalorganisations(NGOs)aregenerallylegalentities,forexampleregisteredwithlocalornational authorities;theymaybeoperativeonlyatcommunitylevelormayalsooperateorbepartofalargerNGOat national, regional and international levels. Some groups that start out as community based organisations register as nongovernmental organisations when their programmes develop and they need to mobilise resourcesfrompartnersthatwillonlyfundorganisationsthathavelegalstatus.
8

Expandedfromthe UNAIDSdefinition:http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/default.asp

Community organisations and actors are all those who act at community level to deliver community based services and activities and promote improved practice and policies. This includes many civil society organisations,groupsandindividualsthatworkwithcommunities,particularlycommunitybasedorganisations (CBOs), nongovernmental organisations (NGOs) and faithbased organisations (FBOs) and networks or associationsofpeopleaffectedbyparticularchallengessuchasHIV,tuberculosisandmalaria.Italsoincludes thosepublicorprivatesectoractorsthatworkinpartnershipswithcivilsocietytosupportcommunitybased servicedelivery,forexamplelocalgovernmentauthorities,communityentrepreneursandcooperatives. Civil society includes not only community organisations and actors but also other nongovernmental, non commercial organisations, such as those working on public policies, processes and resource mobilisation at national,regionalorgloballevels.

WHATISTHEPURPOSEOFTHECSSFRAMEWORK?
TheCSSFrameworkisaimedatstrengtheningcommunitysystemstocontributetokeynationalgoalsandto ensurethatpeoplesrightstohealtharerealised.Thisincludesprevention,treatmentandcare,mitigationof the effects of major diseases and the creation of supportive and enabling environments in which these systemscanfunction. The focus of the Framework is on strengthening community systems for scaledup, quality, sustainable communitybasedresponses.Thisincludesstrengtheningcommunitygroups,organisationsandnetworksand supportingcollaborationwithotheractorsandsystems,especiallyhealth,socialcareandprotectionsystems. It addresses the key importance of capacity building to enable delivery of effective, sustainable community responses. CSS will facilitate effective community based advocacy, creation of demand for equity and good qualityhealthservices,andconstructiveengagementinhealthrelatedgovernanceandoversight. Communitieshaveuniqueknowledgeandculturalexperienceconcerningtheircommunities,whichshouldbe integratedintothedevelopmentandimplementationofcommunityresponses.Thiswillensurethattheyare shaped by accurate knowledge of what is needed, and based on respect for rights and equity of access. Further,thiswillfurtherinfluencesocialchangeandhealthybehavioursandensurecommunityengagementat local,national,regionalandinternationallevels. TheFrameworkisstronglyinformedbyarenewedsensethatcommunityengagementforhealthisessential forachievingthebasichumanrighttohealthforall.TheAlmaAtaDeclarationof1978wasakeystartingpoint, affirming that: ...health is a state of complete physical, mental, and social wellbeing, and not merely the absenceofdiseaseorinfirmity,isafundamentalhumanrightandthattheattainmentofthehighestpossible levelofhealthisamostimportantworldwidesocialgoalwhoserealizationrequirestheactionofmanyother socialandeconomicsectorsinadditiontothehealthsector.9 This fundamental principle was reinforced in the Millennium Development Goals (2000)10; the Abuja Declaration on Malaria (2000)11; the UNGASS Declaration of Commitment on HIV/AIDS (2001)12; and the AmsterdamDeclarationtoStopTB(2000)13.The2008WorldHealthReportadvocatedforrenewaloftheAlma
9

DeclarationofAlmaAtaInternationalconferenceonprimaryhealthcare1978 http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf TheMillenniumDevelopmentGoalshttp://www.undp.org/mdg/basics.shtml TheAbujaDeclarationandPlanofActionhttp://www.rollbackmalaria.org/docs/abuja_declaration_final.htm DeclarationofCommitmentonHIV/AIDShttp://www.unaids.org/en/AboutUNAIDS/Goals/UNGASS/default.asp

10

11 12 13

AmsterdamDeclarationtoStopTB http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf

Atadeclaration,whichbringsbalancebacktohealthcare,andputsfamiliesandcommunitiesatthehubof thehealthsystem.Withanemphasisonlocalownership,ithonourstheresilienceandingenuityofthehuman spiritandmakesspaceforsolutionscreatedbycommunities,ownedbythem,andsustainedbythem.14 Majorconsultationshaveaddressedtheimportanceofstrengtheninghealthservicecommunitypartnerships for the scale up of prevention, care and treatment for HIV, TB, malaria and other diseases. Key aspects addressedwithintheCSSFrameworkincludecollaborationwithcommunityorganisationsin:increasingaccess andadherencetotreatment;developmentofhealthserviceperformanceassessmentguidelines;andtheneed forjointdevelopmentofpartnershipframeworksforbetweencommunities,healthandotherservices.15 TheCSSFrameworkisaflexibletoolthatcanbeadaptedforuseindifferentcontextsandcountries,andnot solelythoseconnectedtotheGlobalFundortothethreediseases(HIV,TBandmalaria)thatarethefocusof the Global Funds mandate. Differentusers will needtoassess at an early stagehowtousetheFramework appropriately for different regions, populations, health challenges and contexts. Within the CSS Framework, communitysystemsareregardedasbeingbothcomplementarytoandlinkedwithhealthsystems,bothwith their own distinct strengths and advantages. The main elements the core components of effective community systems are described and illustrative examples of potential activities, interventions and communitylevelmonitoring&evaluationareprovided. TheFrameworkalsorecognisesthatmajorfundinggapsexistforkeyaspectsofcommunityactionrelatedto healthoutcomes.Ithighlightstheneedtosupportdevelopmentandimplementationofsystemsforpolicyand advocacy,resourcemobilisation,andevidencedrivenprogrammedesignandimplementation.Thiswillenable communityactiontoachievequalityassured,equitable,appropriatedeliveryofinterventionsthatcontribute toimprovedhealthoutcomesandanenablingsociocultural,legal,economicandpoliticalenvironment. The important roles that community actors can and should play in achieving better health outcomes are emphasised,highlightingtheuniqueadvantagesofcommunityorganisationsandnetworksintheirabilityto deliverofserviceswithincommunitiesandwithregardtotheirabilitytoaffectthebroaderdeterminantsof healththatoftenoutweighanyimpactsintendedthroughimprovinghealthserviceaccessanduse.16 17These determinants affect peoples mental and physical health and wellbeing at many levels. They include, for example: income and social or cultural status; education; physical environment; employment and working conditions; social support networks and welfare services; genetics, personal behaviour and coping skills; gender.Communityactorsareinauniquepositiontoworkontheseissuesalongsidehealth,socialwelfareand otheractorsandsystems.Together,theycanachievethescale,rangeandsustainabilityofinterventionsthat willhelptorealisepeoplesrightsandenablethemtoreachimportantgoalsfortheirhealthandwellbeing.18

14 15

TheWorldHealthReport2008:PrimaryHealthCareNowMoreThanEverhttp://www.who.int/whr/2008/en/index.html

Partnershipwork:thehealthservicecommunityinterfacefortheprevention,careandtreatmentofHIV/AIDS;WHO2002 http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf TheDeterminantsofHealthhttp://www.who.int/hia/evidence/doh/en/index.html

16 17

OttawaCharterforHealthPromotion;FirstInternationalConferenceonHealthPromotion WHO1986http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf

18

IncreasingCivilSocietyImpactontheGlobalFundtoFightAIDS,TuberculosisandMalaria StrategicOptionsandDeliberations;BrookKBaker,ICASO2007 http://www.icaso.org/resources/CS_Report_Policy_Paper_Jan07.pdf

Table1: 1. TheCSSFrameworkSixCoreComponentsofCommunitySystems:

Enabling environments and advocacy including community engagement and advocacy for improvingthepolicy,legalandgovernanceenvironments,andaffectingthesocialdeterminantsof health Community networks, linkages, partnerships and coordination enabling effective activities, servicedeliveryandadvocacy,maximisingresourcesandimpacts,andcoordinated,collaborative working; Resources and capacity building including human resources with appropriate personal, technical & organisational capacities, financing (including operational and core funding) and materialresources(infrastructure,informationandessentialcommodities,includingmedicaland otherproductsandtechnologies); Communityactivitiesandservicedeliveryaccessibletoallwhoneedthem,evidenceinformed andbasedoncommunityassessmentsofresourcesandneeds; Organisational and leadership strengthening including management, accountability and leadershipfororganisationsandcommunitysystems; Monitoring&evaluation and planning includingM&E systems, situation assessment,evidence buildingandresearch,learning,planningandknowledgemanagement.

2.

3.

4.

5.

6.

Whenallofthesearestrengthenedandfunctioningwell,theywillcontributeto: improvedoutcomesforhealthandwellbeing, respectforpeopleshealthandotherrights, socialandfinancialriskprotection,and improvedresponsivenessandeffectivenessofinterventionsbycommunities improved responsiveness and effectiveness of interventions by health, social support, educationandotherservices.

Figure1:Overviewofastrengthenedcommunitysystem,withexamples: (CC=corecomponent)

Input
CC1:Enablingenvironments andadvocacy

Output

Impact

Example1:Aftermassdistributionofinsecticide treatedbednets,acommunityactorvisitshomes inhiscommunitytoprovideinformationonthe correctuseofthenetstopreventmalaria.

Example 2: An actor involved with CSS interventions sets up a training programme for CBOs in partnership building and collaborative approachestopolicyandadvocacywork

Example3:Acommunityactorwhoistrainedas TBtreatmentsupportervisitsseveralTBpatients inhercommunityeachdayandensuresthatthey taketheirtreatment

Strengtheninginterventions

CC2:Communitynetworks, linkages,partnershipsand coordination CC3:Resourcesandcapacity building CC4:Communityactivitiesand servicedelivery CC5:Organisationaland leadershipstrengthening CC6:Monitoring&evaluation andplanning

Quality servicesare availableand usedbythe community

Healthis improvedat the community level

Community membersensure thatbednetsare usedbythose mostvulnerable tomalaria TrainedCBOstaff collaboratively advocatefor enhancedstigma reductionpolicies

Reducednumber ofmalariacases inthecommunity

Appropriate stigmareduction policiesareputin placeand increaseaccessto healthcare Numberofcured TBcasesinthe communityis increased

TBpatientshave highadherence levelsand completetheir6 8monthsofTB treatment

WHOISTHISFRAMEWORKFOR?
TheCSSFrameworkisintendedforusebyallthosewhohavearoleindealingwithmajorhealthchallenges and have a direct interest in community involvement and action to improve health outcomes, including community actors, governments, funders, partner organisationss and key stakeholders. Effective and functional community systems are crucial for this, from both organisational and operational perspectives. Strengthening of community systems should be based on a capacitybuilding approach and backed up with adequateandappropriatefinancialandtechnicalsupport. Small community organisations and actors should find the Framework helpful for: planning their work; mobilisingfinancialandotherresources;collaboratingwithothercommunityactors;anddocumentationand advocacyconcerningbarriersandchallengesexperiencedatlocal,national,regionalandgloballevels.These arehighprioritiesforthosewithinorworkingwithkeyaffectedpopulationswhofrequentlyfacedifficultiesin accessingsupportandfundsforkeyactivities.Manycommunityorganisationshavefacedparticulardifficulty ingainingfundingforcoreorganisationalcosts,advocacyandcampaigns,addressingpolicyandlegalbarriers toevidenceinformedprogrammemingandservicedelivery. Largercommunityactors,suchasnetworksofpeopleaffectedbykeydiseasesorNGOs,shouldalsobeableto usetheFrameworkasatoolforscalinguptheirhealthrelatedwork.Itwillhelpthemtofocustheirassistance tosmallerorganisationsthatneedtoadapttheFrameworktolocalneedsandmobilisefundingandtechnical support. In the past, it has been difficult for community actors to explain clearly the connections between healthoutcomesandcommunityactivitiesthathavepotentialimpactsonhealthbutarenotdirectlyrelatedto healthservicedelivery,forexampleadvocacy,socialprotectionandwelfareservices,homebasedcareorlegal services.TheFrameworkprovidesastructureforaddressingthisandenablinginclusionofrelevantnonhealth activitiesinfundingmechanismsandallocationsforhealth. Government bodies and health planners and decision makers should find the Framework helpful for better understanding the varied and vital roles of community actors in health support and promotion. The Framework shows how this role can be part of planning for health and highlights key interventions and systemsthatneedresourceallocationandsupport.Italsohighlightshowmeaningfulinclusionofcommunity actors at national level can contribute to a more balanced mix of interventions through health systems and communitysystemsinordertomaximisetheuseofresources,minimiseduplicationofeffortandeffectively improvehealthoutcomes. PartnerorganisationsandstakeholderssupportingcommunityactorsandreceivingresourcesforCSSactivities will find the Framework helpful for understanding what funding and support are required for community basedandcommunityledorganisationsandwhy,andensuringthefullcontributionoftheseorganisationsto national and global health priorities. The Framework will be of particular interest to organisations and stakeholderssuchas: networksandorganisationsoforforpeoplewithoraffectedbykeydiseases; international,regionalandnationalcivilsocietyorganisationsandnetworksinvolvedinadvocacyand monitoringorwatchdogactivities; nationalfundingmechanisms(suchasGFCountryCoordinatingMechanisms); bilateralandmultilateralorganisationsanddonors; technical partners including UNAIDS and cosponsors, and private sector or nongovernmental technical support providers involved in capacity building, training and technical support for communityactors

2. STRENGTHENINGCOMMUNITYSYSTEMSTOCONTRIBUTETOHEALTH OUTCOMES
WHATISCOMMUNITYSYSTEMSSTRENGTHENING?
ThegoalofCSSistoachieveimprovedhealthoutcomesbydevelopingtheroleofkeyaffectedpopulationsand communities and of community based organisations in the design, delivery, monitoring and evaluation of services and activities related to prevention, treatment, care and support of people affected by HIV, tuberculosis,malariaandothermajorhealthchallenges. Community systems strengthening (CSS) is therefore an approach that promotes the development of informed,capableandcoordinatedcommunitiesandcommunitybasedorganisations,groupsandstructures. Itinvolvesabroadrangeofcommunityactorsandenablesthemtocontributetothelongtermsustainability ofhealthandotherinterventionsatcommunitylevel,includingan enabling and responsive environment inwhichthesecontributionscanbeeffective. Keyunderlyingprinciplesofcommunitysystemsstrengtheninginclude: Significantandequitableroleinallaspectsofprogrammeplanning,design,implementationand monitoringforcommunitybasedorganisationsandkeyaffectedpopulationsandcommunities,in collaborationwithotheractors; Programmemingbasedonhumanrights,includingtherighttohealthandnondiscrimination; Programmeminginformedbyevidenceandresponsivetocommunityexperienceandknowledge; Commitmenttoincreasingaccessibility,uptakeandeffectiveuseofservicestoimprovehealthand wellbeingofcommunities; Accountabilitytocommunitiesforexample,accountabilityofnetworkstotheirmembers, governmentstotheircitizens,anddonorstothecommunitiestheyaimtoserve. StrategiesforCSSwhichareessentialtotheCSSapproachandarereflectedintheCSSFrameworklistofCore Componentsinclude: Developmentofanenablingandresponsiveenvironmentthroughcommunityleddocumentation, policydialogueandadvocacy Supportbothforcorefundingforcommunitybasedorganisationsandnetworks,including organisationsaloverheadsandstaffsalariesandstipends,aswellastargetedfundingfor implementationofprogrammesandinterventions; Capacitybuildingforstaffofcommunitybasedorganisationsandnetworksandforothercommunity workers,suchascommunitycareworkersandcommunityleaders. Networking,coordinationandpartnerships Strategicplanning,monitoringandevaluation,includingsupportforoperationalresearchand generationofresearchbasedandexperientialevidenceforresultsbasedprogrammeming. Sustainabilityoffinancialandotherresourcesforcommunityinterventionsimplementedby communitybasedorganisationsandnetworks.

WHATNEEDSSTRENGTHENING?
Thestrategiesoutlinedaboveindicatethepriorityareasforstrengtheningforthesystemsusedbycommunity based organisations and other community actors. Systems for organisation and delivery of activities and

8 services19 are integral to any organised programme or service, whatever the size, structure or status of the groupororganisationthatimplementsthem.Inpractice,thesystemsofoneactorareoftenlinkedtothoseof otheractorstoprovideafunctionaloverallsystem;forexampleawelldevelopedcommunitysystemforcare andsupportmightincludespecificsystemsforprovidingcounselling,forpolicyadvocacy,forlegalsupport,for referralandaccesstoservicesandfollowup,forhomebasedcare,andforsocialprotectionandwelfareof vulnerablechildren,youthandadults. The diagram below shows how different actors, working together or separately, use systems to implement services and activities, providing results at the levels of outputs, outcomes and impacts. Effective and functional systems play an enabling role for actors to deliver activities and they are therefore crucial for contributingtomeaningfuleffectsonhealthand/ornonhealthfactors.Healthandnonhealthoutcomescan bothcontributetohealthimpacts.However,thefunctioningofsystemsandtheirresultsalsodependsonthe influenceoffactorsinthesurroundingenvironmentwhichmayenableordisableeffectiveservicedeliveryand functioningofsystems.

Community Actors

Health Actors Outputs

develop&manage thatleadto Health outcomes Otheroutcomes

Systems thattheyusetodeliver

Resultingin:

whichinturncontributeto

Activities/services forcommunities

Impactsonhealth

Figure2:Communityactionandresultsforhealth Community systems strengthening is not only a way to improve access to and utilization of formal health services. It is also, and crucially, aimed at increased community engagement meaningful and effective involvementasactorsaswellasrecipientsinhealthcare,advocacy,healthpromotionandhealthliteracy, health monitoring, homebased and community based care and wider responses to disease burdens. It includesdirectresponsesbycommunityactorsandalsotheirengagementinresponsesofotheractorssuchas public health systems, local and national governments, private companies and health providers, and cross sectoralactorssuchaseducationandsocialprotectionandwelfaresystems. The importance of creating enabling legal, social, political and economic environments should not be underestimated.Anenablingenvironmentisessentialforpeopletoachievetheirrightsandforcommunities
19

Programmematicinterventionsbycivilsocietyactorsareoftencalledactivities;inhealthsystems, interventionsareusuallycalledservices;theGlobalFundandotheragenciesusethetermservicedeliveryarea tocoverthefullrangeofprogrammematicactivitiesandservicesthisisakeytermusedinthisFramework.

andcommunityorganisationstobeengagedandeffective.Thecontextsofinterventionstoimprovehealthare always multilayered, and effectiveness of interventions can be seriously impaired in environments that are hostile or unsupportive. As the Ottawa Charter points out, the ...fundamental prerequisites for health are: peace,shelter,education,food,income,astableecosystem,sustainableresources,socialjustice,andequity. Improvement in health requires a secure foundation in these basic prerequisites. Ensuring that the basic conditions and resources for health are able to support all citizens is only possible through the combined efforts of communities, governments, civil society and the private sector. More effective community engagementandstrongerpartnershipsbetweencommunity,publicandprivateactorsarethereforeessential in order to build enabling and supportive environments and to scale up effective responses by community, healthandsocialwelfaresystems. Communitybasedorganisationsarerichinexperienceandclosetocommunitiesbuttheyareoftenthemost poorly resourced in financial terms. CSS must therefore prioritise adequate and sustainable funding for community actors not only project funds for specific operational activities and services but,crucially, core funding to ensure organisational stability as a platform for operations and for networking, partnership and coordinationwithothers.Unrestrictedcorefunding,basedonagreedstructuresandprocedures,contributes to sustainability by ensuring continuity and allowing an organisation to have the appropriate paid staff, suppliesandinfrastructuretobuilduptheirchosenprogrammesinresponsetotheneedsofthecommunities theyserve. CSS must also have a strong focus on capacity building and human resources so that community actors can playafullandeffectiverolealongsidestrengthenedhealthandsocialwelfaresystems.Community,healthand social welfare systems must increase their commitment to health equity and an enabling sociocultural environment.They muse emphasise the role of key affected populations as the drivers andcontributors for improvinghealthoutcomesaswellasensuringequitableaccesstoservicesandsupportforhealthrights. All actors community organisations, local and national governments, health, social and education systems andothersneedtodevelopagreaterunderstandingofthepotentialoutcomesandimpactsofcommunity engagement,andofthewaysinwhichinterventionsarebestimplementedbyandwithcommunities.Itisalso essentialthatcivilsocietyactors(suchasfaithbasedandnongovernmentalorganisationsororganisationsfor people affected by major diseases) should base their activities and services on national standards and guidelinesandinternationalbestpracticeguidancewherevertheseexist.Thisensuresthatcommunityactors playtheirroleinreachingnationalhealthgoalsaswellasconcentratingonlocalneedsandinterventions. Bytheirverynature,communitiesareorganicanddiverse,andagreatvarietyofgroupsandorganisations community actors arise in response to perceived community needs.2021 At their simplest, they may lack formalstructuresorcapacityforrunningadministrativesystems,managingfundsorcommunicatingeffectively withofficialsandotherorganisations.Largercommunityorganisationsmayhavethoseskillsandcapacitiesbut maybeworkinginisolationfromeachotherandfrommainstreamgovernmentsystems. Insomecontexts,communityactorsoperateoutsideofmainstreamsystemsinordertoreachpeoplewhoare marginalised or criminalised or do not trust official systems for example, undocumented migrants, sex workers, sexual minorities or drug users. Sometimes community actors are themselves isolated from the mainstream,duetobarrierswithinthecountryortodonorprocessesthatpreventthemfromactingasequal partnersinplanning,implementation,oversightandassessmentofprogrammes.
20

Exploringtheconceptofcommunity:implicationsforNGOmanagement;JodeBerry2002,LondonSchoolofEconomics http://www.lse.ac.uk/collections/CCS/pdf/IWP/IWP8deberry.PDF

21

CommunityOrganizingandCommunityBuildingforHealth;MeredithMinkler(2004)RutgersUniv.Press http://rutgerspress.rutgers.edu/acatalog/__Community_Organizing_and_Community_Building_for__664.html

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Insomesettingsthereisexcellentcooperationbetweendifferentactors,butitisimportantnottooverlook the inequalities, social hierarchies, discrimination and competitiveness that sometimes operate between community organisations, and between them and government structures. Creating and maintaining good workingrelationships,andensuringadequate,equitableandsustainablefundingforcommunityorganisations andactorsarethereforekeyprioritiesforstrengtheningandscalingupcommunitysystems.22

WHATHEALTHRELATEDACTIVITIES&SERVICESDOCOMMUNITYSYSTEMSDELIVER?
Through community systems, community actors currently provide several categories of activities or services thatdirectlyorindirectlyaffecthealthoutcomes.Thesecategoriesarenotmutuallyexclusiveandthereare many synergies and overlaps within and between community systems and health systems, especially within integratedpackagesofcare,supportandprotection. Itisalsoimportanttorecognisethatcommunitybasedandcommunityledorganisationshavedifferentroles dependingonwhichhealthchallengestheyareworkingon.Fortuberculosis,forexample,theemphasisison the partnership of people with TB and their communities with political and health institutions to achieve betterhealthforallanduniversalaccesstoessentialcare.Theprimaryaimistoensurethequality,reachand effectivenessofhealthprogrammesforpreventionandtreatment.Formalaria,thereisasimilaremphasison partnerships and on the communitys role in malaria control, primarily through improved community knowledge, prevention behaviours and access to prevention commodities, and to accurate diagnosis and effective treatment. Where HIV is concerned, there are marked differences between generalised epidemics affecting many people within geographical areas, and focused epidemics affecting specific groups of people whoareconsideredtobecommunitiesduetotheirhealthorlegalstatusandtotheirspecificvulnerabilities toHIVandtostigmaanddiscrimination. In many parts of the world, of course, communities are affected by all three diseases and by many other challengestohealth.Communitiesofeverykindneedtobeabletoaccessserviceseasilytoaddressalltheir differingneeds.Currently,thereisincreasingunderstandingoftheneedforintegratedprogrammemingand deliverynotjustofhealthservicesbutcombinationsofhealth,social,education,legalandeconomicsupport. Communitybasedorganisationsandnetworkshaveavitalroletoplayinthedevelopmentofsuchintegrated andcommunitydrivenapproaches. TheWHOdefinitionofahealthsystemcomprisesallorganisations,institutionsandresourcesdevotedto producing actions whose primary intent is to improve health. In practice, government health systems have limitedresourcesandareoftensupplementedbynongovernmentproviderssuchasfaithbasedorganisations (FBOs), CBOsor NGOs working in collaboration with government systems or in parallel systems that may or may not be linked with national health systems. Much nongovernment health system input happens at communitylevel.Communitysystemsthushavearoleintakinghealthsystemstopeopleincommunitiesand in providing community inputs intohealth systems. At the same time, health systems are just onepart ofa widersetofsocialsupportsystemsthatarerelevanttopeopleshealthandwellbeing. Threemaincategoriesofcommunitylevelactivitiesandservicesthatsupporthealthindifferentwayscanbe described, as shown below. However, the interface between government and community healthrelated services depends on the local context. For purposes of definition, it is probably best to distinguish health systeminterventionsfromothersbasedonwhattheinterventionisratherthanwhoisprovidingit.Totakean obvious example from the first category below, provision of TB medication is clearly a health system intervention,whichmaybeprovidedbythenationalhealthsystem,byafaithbasedorganisationoranother communityactor.Examplesinthesecondcategorybelowarehealthfocused,butthebestoptionfordelivery
22

Strengthening Community Health Systems: Perceptions and responses to changing community needs; CADRE 2007. http://www.cadre.org.za/node/197

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at community level may be through functioning community systems rather than through the formal public healthsystem. Concentration on formal health systems and lack of clarity about the complementary and crucial role of communitysystemshasledtoconflictingopinionsonwhereinterventionsintheothertwocategoriesshould be placed in relation tofundingand monitoring. Thisconflict remainsto be resolved, but it is essential that suchinterventionsshouldnotbesidelined.Clearsignalsshouldbegiventodecisionmakersatinternational and national levels that funding for CSS and community service delivery must include all categories of communityledandcommunitybasedinterventions.Thesupportinterventionslistedinthesecondcategory arethosewherecommunityactorsprovideaddedvaluetohealthsysteminterventionsfundingthemunder CSS may in many circumstances be a more helpful strategy in order to ensure that communities gain full benefit. i. Directprovisionofhealthservicesincooperationwithorseparatelyfrompublichealthservices: Diagnosis,treatmentandcarethroughcommunitylevelfacilitiessuchasclinics,hospitals,laboratory services23, Community delivered health interventions such as mobile HIV counselling & testing, treatment followup24orcrosscuttinghealthinterventions25 Diseasepreventionactivities26 Communityhealthservicessuchashomebasedcare,TBDOTSetc27 Communityhealtheducationandpromotion Servicestoneglectedandvulnerablepopulations Implementationandmonitoringofpoliciesthataffectaccesstohealthandwelfareservices Supportactivitiesforindividualsaccessinghealthrelatedservicesatcommunitylevel: Community mobilisation for access to and use of health services in a health friendly local environment; Comprehensivehomebasedcare; Referralsandsupportforaccesstohealthandotherservices; Supporttoindividualsforserviceuseandfollowup; Diseaseprevention,harmreductionandbehaviourchangeinterventions; Increasingcommunityliteracyontestinganddiagnosis, Treatmentliteracyandadherencesupport; Reducingstigmaanddiscrimination; Advocacyandaccesstolegalservices Psychological,socialandeconomicsupport; Communitybasedhealthinsuranceschemes;

ii.

23

CivilSocietySupportandTreatmentAccess;FakoyaA,AbdefadilL,PublicServiceReview:InternationalDevelopment#14, June2009http://www.publicservice.co.uk/article.asp?publication=International Development&id=391&content_name=Treatmentaccess&article=12197

24

RatesofvirologicalfailureinpatientstreatedinahomebasedversusafacilitybasedHIVcaremodelinJinja,southeast Uganda:aclusterrandomisedequivalencetrial;JaffarS,BAmuronetal(2009)Lancet http://www.thelancet.com/journals/lancet/article/PIIS01406736(09)616743/abstract

25

Community directed interventions for major health problems in Africa. A multicountry study; WHO 2008 http://apps.who.int/tdr/svc/publications/tdrresearchpublications/communitydirectedinterventionshealthproblems

26

Advocacy,communication&socialmobilisation(ACSM)fortuberculosiscontrolahandbookforcountryprogrammes; StopTBPartnership,2007http://whqlibdoc.who.int/publications/2007/9789241596183_eng.pdf

Homeiswherethecareis.TheroleofcommunitiesindeliveringHIVtreatmentcareandsupport;AbdefadilL,FakoyaA, PublicServiceReview:InternationalDevelopment#15,September2009 http://www.publicservice.co.uk/pub_contents.asp?id=401&publication=International Development&content=3850&content_name=Health

27

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Financial support for accessing services, such as cash transfers and assistance with outofpocket expensesfortransport,foodwhileawayfromhomeetc.

iii. Activitiestocreateandimprovetheenablingenvironment: Socialdeterminantsofhealth Participationinlocalandnationalforaforpolicychange; Advocacyandcampaigns; Community awareness on gender, sexual orientation, disability, drug dependency, child protection, harmfulsocioculturalpracticesetc; Peeroutreachandsupport; Servicesfor:literacyandaccesstoinformation;legalredress;individual&familysocialsupport(social transfers);welfareservices;andrehabilitation; Educationalservicesandsupportforchildrenandyouth Community mobilisation on stigma & discrimination, basic rights, poverty reduction, access to services,information,commodities(e.g.condoms,medicinesetc); Oversight,monitoringandevaluationofimplementationofprogrammesandservices; Broaderdeterminantsofhealth Participationinlocalandnationalforaforpolicychange; Nutrition,housing,water,sanitationandothermaterialsupporttovulnerablechildrenandadults; Livelihood support programmes such as microcredit or savings schemes, training schemes for unemployedadultsandyouthandforgrowingfoodtosupportfamilies. Supportforcivilrightsandaccesstoservices,forexamplecivilregistrationofbirthsanddeaths

COMMUNITYSYSTEMSANDHEALTHSYSTEMSCOMPLEMENTARYANDCONNECTED
Community systems are complementary to and closely connected with health systems and services. As outlinedabove,bothtypesofsystemsengageindeliveryofhealthservicesand,toagreaterorlesserdegree, insupportingcommunitiesforaccesstoandeffectiveuseofthoseservices.Inaddition,communitysystems haveuniqueadvantagesinadvocacy,communitymobilisation,demandcreationandlinkageofcommunitiesto services. They also have key roles in health promotion and delivery of community health services, and in monitoring health systems for equity and quality of services. Community actors are also able to play a systematic, organised role in advocacy, policy and decisionmaking and in creating and maintaining and enablingenvironmentthatsupportspeopleshealthandreducestheeffectsonvulnerablepeopleofpoverty, discrimination,marginalisation,criminalisationorexploitationandharmfulsocioculturalpractices. Lackofclarityinthepasthasmadeitdifficulttodiscusshowcommunitysystemsrelatetohealthoutcomes andhowtheylinkwithhealthsystems.Onereasonmaybethatcommunitysystemsareoftenmorefluidand hardertodefinethanthestructuredsystemsofahealthorsocialsupportservice.Anotherreasonisthatitis difficulttodefineexactlywhattheboundariesbetweenhealthandcommunitysystemsare,andtoidentifythe linksbetweenthem.Thisisespeciallythecasewhencommunityactorsaredirecthealthcareprovidersand major contributors to health through homebased and facilitybased services. Another reason is that community and homebased care, mainly provided by women and girls, is often undervalued because of genderedassumptionsaboutseparationofpublicandprivatecareandaboutthenonprofessionalstatusof voluntarycareworkprovidedbywomenandchildren. Inadditiontogainingclarityabouttherelationshipbetweenhealthsystemsandcommunitysystems,itisalso importanttobeclearabouthowcommunitysystemsmayhavecomparativeadvantagewithrespecttocertain healthrelated activities. These are specific to local contexts, but may include ensuring that services and support are available close to peoples homes, using the language skills of trusted, culturally competent community members, ensuring continuity of followup for people with chronic diseases, communitylevel

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promotion of health literacy, social and psychological support, changing harmful sociocultural practices, outreachtokeyaffectedcommunitiesandindividuals,andprovidingrespiteforhomebasedcarers. Thelackofclarityaboutcommunitysystemsandtheircomparativeadvantageshasalsoresultedinlimitedand inconsistentfundingforcommunityactivitiesorservices,andfororganisationalstrengtheningofcommunity actors.Therehasbeensimilarunderfundingintheareaofsocialprotectionandwelfareservices,especially regardingpeoplelivingwithoraffectedbyHIV.Forexampleresourcesareneeded(buthardtomobilise)to support people with out of pocket expenses incurred in accessing services, to accompany sick people to hospital,toprovidefamilycentrednutritionalsupportforpeopletakingantiretroviralorothermedication,and toimplementcommunitybasedchildprotection. Much more evidencebuilding and research is needed on community systems and the role of community organisationsandactorsinhealthsupportforvulnerablecommunities.Thisappliesespeciallytointerventions indirectlyrelatedtohealth(suchasthosefocusedonpovertyorotherhealthdeterminants)andforhealth relatedsupportinterventionsfocusedonprevention,access,careandadvocacyratherthandirectdeliveryof medical services. Support and resources for research on the health consequences of communityled interventions have been very limited or even nonexistent in the past and need to be prioritised now, especially since funders increasingly require that all programmes and interventions be measurable and evidencebased. Healthsystemsarenotsomethingseparatedfromcommunities.Theyarekeycommunityassets,partofthe networkofrelationshipsandsupportthatindividuals,familiesandcommunitiesareentitledtorelyon.Clearly, there are synergies as well as overlaps between health systems, community systems and social welfare systems,buttheseshouldbeusedasastimulusforcreativeandinnovativeapproachestobringcommunity, healthandsocialsystemsintocloserandmorecomplementarypartnerships.28

Social,Cultural,Economic,PoliticalandLegal Environments

Community Actorsand Systems

Health Actorsand Systems

Areaofoverlaps,synergies,cooperation,joint actionbetweencommunityandhealth

Figure3:Communityandhealthactors&systems complementaryandconnected
28

Supportforcollaborationbetweengovernmentandcivilsociety:thetwintrackapproachtostrengtheningthenational responsetoHIVandAIDSinKenya;FuturesGroupEurope2009 http://www.futuresgroup.com/wpcontent/uploads/2009/11/FGEBriefingPaperNovember2009.pdf

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3. THECORECOMPONENTSOFAFUNCTIONALCOMMUNITYSYSTEM
ThissectiondefinessixcorecomponentsforCSS.Thesemustallbeinplaceandfunctioningeffectivelyinorder forcommunitysystemstocontributefullyandsustainablytohealthoutcomes,bothdirectlyandindirectly. Service delivery areas (SDAs) are suggested for each core component, with illustrative lists of activities. Chapter 4 of the Framework provides suggested indicators for each SDA suggested here. The SDAs and indicatorsarenotmandatoryusersoftheFrameworkmaywishtosubstituteotherSDAsiftheyaremore appropriateforthenationalorlocalcontextandplans.DetailedindicatordescriptionsaregiveninAnnex1. The core components described below are all regarded as essential for building strong community systems. Together,theywillenableCBOsandothercommunityactorstodeliveractivitiesandserviceseffectivelyand sustainably.Theyalsosupportdevelopmentofstronglinksandcoordinationbetweendifferentsystemsand actorsworkingtowardsthesharedgoalofimprovinghealth. CSS should always start with an analysis of how systems are already functioning, how they need to be strengthenedandhowtheycanbebuiltintoafunctionalandcoherentwhole.CSSisagradualprocessand interventions should focus on addressing all the individual components and their combined functioning, in ordertoassuredeliveryofquality,equitable,appropriateandsustainableinterventionsandoutcomeswithin empoweredcommunities. Table2:SummaryofCSSCoreComponents,andcharacteristicsofstrengthenedServiceDeliveryAreas(SDAs): Corecomponents (notinorderof priority;allare essential) 1. Enabling environmentand advocacy ServiceDeliveryAreas (notinorderofpriority;may bereplacedwithotherSDAs ifmoreappropriateto nationalsituations) SDA1:Monitoringand documentationof communityandgovernment interventions SDA2:Advocacy, communicationandsocial mobilisation CharacteristicsofstrengthenedSDAs (asetofsubgoalsforCSS,indicatinghowafully functionalcommunitysystemcanberecognisedwhen communitysystemstrengtheninghasbeen successfullyachieved) Communitybasedorganisationsanalyzeand documentrelevantissuesandplanandimplement involvementinpolicyactivitiesatappropriatelevels.

Communitieseffectivelyadvocateforimplementation andimprovementofnationalprogrammes.Well informedcommunitiesandaffectedpopulations engageinactivitiestoimprovetheirown environment. Functionalnetworks,linkagesandpartnerships betweencommunityactorsandnationalprogrammes areinplaceforeffectivecoordinationanddecision making.

2.

Community networks, linkages, partnershipsand coordination Resourcesand capacitybuilding

SDA3:Buildingcommunity linkages,collaborationand coordination

3.

SDA4:Humanresources: skillsbuildingforservice delivery,advocacyand leadership

Communityactorshavegoodknowledgeofrights, communityhealth,socialenvironmentsandbarriers toaccessanddevelopanddelivereffective communitybasedservices.

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SDA5:Financialresources

Communityactorshavecorefundingsecuredand mobilizeandmanagefinancialresourcessustainably. Financialreportingistransparent,timelyandcorrect. Functionalsystemsareinplacetoforecast,quantify, source,manageanduseinfrastructureandessential commoditiesinappropriateandefficientways.

SDA6:Materialresources infrastructure,information andessentialcommodities (includingmedicalandother productsandtechnologies) 4. Community activitiesand servicedelivery SDA7:Communitybased activitiesandservices delivery,use,quality

Effective,safe,highqualityservicesandinterventions areequitablydeliveredtothoseinneed.

5.

Organisationaland SDA8:Management, leadership accountabilityand strengthening leadership

Whileensuringaccountabilitytoallstakeholders communityactorsprovideleadershipinthe development,operationandmanagementof programmes,systemsandservices. Relevantprogrammematicqualitativeand quantitativedataiscollected,analyzed,usedand shared.Appropriatemechanismsfordataquality, feedbackandsupervisionareinplace. StrategicinformationgeneratedbytheM&Esystemis usedforevidencebasedplanning,management, advocacyandpolicyformulation.

6.

Monitoring& evaluationand planning

SDA9:Monitoring& evaluation,evidence building

SDA10:Strategicand operationalplanning

CORECOMPONENT1:ENABLINGENVIRONMENTSANDADVOCACY
Communitiesneedanenablingenvironmenttofunctioneffectivelyandensurethattheirrightsarerespected andtheirneedsaremet.Theenvironmentshouldalsobeoneinwhichcommunityvoicesandexperiencescan be heard and in which community based organisations can make effective contributions to policies and decisionmaking. Thisenablingenvironmentincludesthesocial,cultural,legal,financialandpoliticalenvironmentsaswellasthe daytoday factors that enable or hinder peoples search for better health. For example, access to health services, education, adequate food, water and shelter, sexuality and family life, security. At the same time, peoplealsoneedfreedomfromsuchthingsas:harassment,discrimination,violenceandharmfulsociocultural practices.Allofthesefactorscaneithersupportorhindersuchthingsasaccesstoservices,accesstofunding and the ability of community organisations to function effectively. Failure to address them will increase the riskthatinterventionsforhealthmayfailorbeunsustainable. Establishing and sustaining the enabling environment is a priority that should not be neglected. These processses should receive adequate funding as an investment for health and to support the establishment, working and strengthening of community based organisations and systems. The contexts of major diseases such as HIV, tuberculosis and malaria (and many others) are always multifactored, and effectiveness of interventions can be seriously impaired in environments that are unsupportive or hostile. For example:

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adherence to treatment regimens is always at risk in environments with high levels of stigma and discrimination; prevention and harm reduction interventions may be extremely difficult or impossible to deliverwhencertaingroupsofpeoplesuchasdrugusersorsexworkersarecriminalisedand/ormarginalised. Communitymonitoringanddocumentationarepowerfultoolsforadvocacyandpolicydialogue,forexample whentherearerightsviolationsoraccesstoservicesisrestricted.Communitiesandcommunitynetworkshave awatchdogroleandareabletomobilisecommunitiestowardscreatingmorefavourableenvironments.They are able to work with policymakers and implementers to redress specific problems experienced by communitiesandscaleuptheresponsesforallsectorsofthepopulation. Support will be needed to develop effective community action for the enabling environment at community level. This will empower communities and key affected populations to communicate their experiences and needstodecisionmakersatalllevels,throughlinkagesatcommunitylevelandthroughcoalitions,networks andcivilsocietyadvocacygroupsthatoperateinnational,regional,andinternationalfora.

SDA1:MONITORINGANDDOCUMENTATIONOFCOMMUNITYANDGOVERNMENTINTERVENTIONS
Rationale: Community members and organisations are uniquely positioned to effectively monitor and documenttheexperiencesofkeyaffectedpeopleandcommunities,thequalityandreachofservicesandthe policiesthatarebeingimplementedatcommunitylevel.Inordertofulfilthiscriticalrole,communitybased organisations and networks need to improve their capacity to collect and analyze data, including strategic choices about what data to collect, and how to target and use it effectively. Strong communityled documentation and monitoring will contribute to more efficient, responsive, and accountable structures at communityandhigherlevels,providingfeedbacktogovernmentandcivilsocietyorganisationsandsupporting greater cooperation and accountability. Monitoring anddocumentation will also contribute to engaging and empowering community members, who often feel they have little or no role in planning and design of programmesinwhichtheyareexpectedtoplayarole,forexampleindiseasepreventionorcommunityhealth care. Examplesofactivities: Developingandimplementing,incollaborationwithotheractors,planstoincreasegovernmentbuyinfor dealingwithpublichealthchallenges; Developingandimplementing,incollaborationwithotheractors,planstomonitorimplementationof publicpoliciesandservicesrelatedtohealthandsocialsupport; Lobbyingforbettergovernanceondecisionmaking,policymakinganduseofresourcesbypublic institutions; Participationofcommunityactorsinnationalconsultativeforums; Advocacyonlegalandpolicyframeworkse.g.decriminalisationofbehavioursormarginalisedgroups; developmentandenforcementofchildprotectionpolicies; Contributingcommunityexperienceandperspectivestodevelopmentofnationalstrategies,including crosssectoralandsectorwideapproaches; Mappingcommunicationneedsandplanningstrategiesforinterventionswithpolicyanddecisionmakers; Capacitybuildingforcommunicationthroughmediaradio,television,print; Developingcommunicationmaterialsforspecificaudiencese.g.children,women,sexualminoritiesetc; Developingrelationshipswithkeypartnersforresourcemobilisation.

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SDA2:ADVOCACY,COMMUNICATIONANDSOCIALMOBILISATION
Rationale: Communitybasedorganisationsandnetworkshaveanimportantroletoplayinengagingwithgovernments and other institutions at all levels (local, national, regional and global) to use wellinformed dialogue and discussiontoadvocateforimprovedpoliciesandpolicyimplementation.Inordertoplaythisrole,community based organisations and networks need support and assistance to create and implement effective communicationandadvocacyplans,andtodevelopsystemsforworkingwithpartners,governmentagencies, media, and broader constituencies. They also have a key role in communication and social mobilisation to engage communities at local level. For example, they may advocate to change discriminatory practices, policiesandlaws,workforsocialchangesthatsupportbetterpreventionandcareseeking,andparticipatein publiccampaignsforimprovedqualityandreachofservices.Communityorganisationsandnetworksarealso vital for bringing together the broader community and other stakeholders to collaborate in maintaining or improvingtheenablingenvironment. In order to play these roles, community based organisations and networks need support and assistance to createandimplementeffectivecommunicationandadvocacyplansandtosetupandimplementsystemsto enable them to work with community members, partners, media, government and broader constituencies. Depending on local and national conditions, work on advocacy, communication and social mobilisation will depend on a range of different activities, such as direct dialogue with decision makers and influencers, community consultations and dialogues, letterwriting and petitions, use of new and traditional media and publiccampaigns. Examplesofactivities: Mapping of challenges, barriers and rights violations experienced by key affected populations and developingpolicyanalysis,recommendationsandstrategiestoimprovetheenvironment; Mappingofexistingdocumentationonlegalandotherbarriersordocumentnewones; Mobilizationofcommunitiesandkeyaffectedpopulationstoengageactivelywithdecisionmakers,and representcommunityissuesinmajordiscussionforumsrelatingtohealthandrights; Mobilizationofkeyaffectedpopulationsandcommunitynetworkstoengageincampaignsandsolidarity movements; Informingandempoweringcommunitymemberstocommunicateandadvocateforchangeandimproving enablingenvironmentsatlocallevel; Policydialoguesandadvocacytoensurethatissuesofkeyaffectedpopulationsarereflectedinallocation ofresourcesandinnationalproposalstoTGFandotherdonors,andNationalStrategicPlans; Documentationofkeycommunitylevelchallengesandbarriersanddevelopmentofadvocacymessages andcampaignstocommunicateconcernsofaffectedpopulations; Promoteandensurecommunityrepresentationinpolicy,planningandotherdecisionmakingbodies; Activelyengaginginpolicydialogueandadvocacywithglobal,regional,subregionalandnationalNGOs, majorinternationalpartnerssuchasTGF,UNAIDS,StopTB,RollBackMalariaandotherforumssuchas highlevelmeetings(HLM)relatingtoMDGsandUNGASS.

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CORECOMPONENT2:COMMUNITYNETWORKS,LINKAGES,PARTNERSHIPS&COORDINATION
Functioning community networks, linkages and partnerships are essential to enable effective delivery of activitiesandservices.Stronginformalandformalrelationshipsbetweencommunities,communityactorsand otherstakeholdersenablethemtoworkincomplementaryandmutuallyreinforcingways,maximisingtheuse ofresourcesandavoidingunnecessaryduplicationandcompetition.29 Anetworkisasystemforconnectingpeoplewithcommoninterests.Alinkageisaconnectionthathelpsto connect a person or organisation to others. A partnership is a more formal agreed relationship between peopleororganisationsinwhichtheyshareresourcesandresponsibilitiesinordertoachievecommongoals. Networks often have multiple functions, for example networks of people living with HIV and AIDS or other healthchallenges.Manynetworksconcentrateonexchanginginformation,experiencesandlearning,andon mutual support for advocacy, strategy development, capacity building and resource mobilisation. Some communitybasednetworksareformallyorganised,forexamplenetworksofpeoplelivingwithHIVadvocating forbetteraccesstolegalsupport,orvillagehealthcommitteesmobilisingsupportforbettermalariadiagnostic equipmentatlocallevel.However,informalnetworksalsohaveimportantrolesatcommunitylevel,sharing information,providingsupporttoindividualsandbringingaboutchangeinthecommunity,suchasworkingto removestigmaanddiscriminationagainstpeoplewithTBand/orHIVoreducatingpeersondiseaseprevention andchanginghealthrelatedbehaviours. Strongnationalandregionalnetworksofkeyaffectedpopulationsandcivilsocietygroupscanmakeimportant contributions to the accountability of government and nongovernment bodies and organisations and to supportingcommunitybasedactivitiesandservicedelivery.Networksalsohaveavitalroletoplayintechnical assistance, due to their ability to act as knowledge hubs, contribute to development of communities of practice,anddistributeappropriateinformationthroughtheirnetworks,forexampleontechnicaltools,good practices and consultants. Strengthening networks for the role of advocates, watchdogs, and technical assistance providers is therefore likely to be an effective investment towards effective implementation of servicedeliveryandcontributingtowardsthebroaderenvironmentforhealth. Where advocacy by national networks is challenged, for example by stigma or discriminatory laws, regional networks can represent the needs of key affected people and communities and act as watchdogs. They are alsovitalforknowledgemanagementandsharingofgoodpractices,toolsandinformationbetweencountries withsimilarculturalbackgroundsandneeds.Thisleadstosignificantaddedvalueasexperienceissharedmore broadlyandduplicationofeffortisprevented.Partnershipsbetweenorganisationswithsharedobjectivescan developjointapproachestocommunityledservicedeliveryandprovideeachotherwithoperationalsupport. For example they may work together on financial and other resource mobilisation, shared planning and deliveryofactivitiesandservices,shareduseofcommunitybasedfacilitiesorsharedprocurementofhealth andothercommodities.

SDA3:BUILDINGCOMMUNITYLINKAGES,COLLABORATIONANDCOORDINATION
Rationale:Fundingandsupportisrequiredtobuildandsustainfunctioningnetworks,linkagesand partnerships,improvecoordinationanddecisionmaking,enhanceimpactsandavoidduplicationofactivities andservices.Wherelocalornationalcommunityandkeyaffectedpopulationnetworksareweakorlackkey capacities,regionalnetworkscanplayasignificantroleinassistingwithconsultationandaccountabilityof governmentandnongovernmentactors
29

NationalPartnershipPlatformsonHIVandTB:Atoolkittostrengthencivilsocietyinformation,dialogueandadvocacy; HDN/IHAA/SAfAIDS/AIDSPortal,December2009 http://aidsalliance.photolinknewmedia.com/Publicationsdetails.aspx?Id=430

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Examplesofactivities: Developandmaintaincoordinationmechanismsandagreementsorcontractualarrangementstoenable communityactors,CBOsandNGOstocollaborateandworktogether; Developandmaintaincoordinationmechanismsagreementsorcontractualarrangementswithpartners andstakeholdersatlocal,national,regionalandinternationallevels; Developcommunicationplatformstosharecommunityknowledgeandexperiencesandsupport networks; Developnationalpartnershipplatformsandnationalleveladvocacycoordinationmechanisms; Networkingandpartnershipdevelopmentbetweencommunityandotheractors,foraccesstoservices, particularlyforthemostaffectedpopulationgroups; Sharingofknowledgeanddevelopmentofplanstoinvolvecommunitymembersandotherstakeholders toplayrolesindesign,implementationandoversightofprogrammesoractivities; Empowermentofcommunityactors,particularlyCBOSandsmallorganisations,toparticipateeffectively innetworkingandpartnershipsforservicedeliveryatlocallevel; Developmentofcommunityactorlinkagestolocal,nationalregionalandinternationalcoordination bodies; Operationalsupportforimplementationofcoordinationactivities,suchastravel,perdiem, communicationandoverheadcosts; Developmentofcommunityactorlinkagesandcollaborationinlocalandnationalcoordinationbodies; Createcommunitybasednetworksformalaria,TBorotherdiseaseinitiatives; Createnetworkingstructureswithlocalauthoritiessuchascouncils,districtcommitteesetc; Contributetoimprovedknowledgemanagementbysupportingsharingofinformation,tools,good practicesetcwithincommunities.

CORECOMPONENT3:RESOURCESANDCAPACITYBUILDING
Resourcesforcommunitysystemsinclude: humanresourcespeoplewithrelevantpersonalcapacities,knowledgeandskills; appropriatetechnicalandorganisationalcapacities;and materialresources,includingadequatefinance,infrastructure,informationandessentialcommodities. Theseresourcesareessentialforrunningsystemsandorganisations,andfordeliveringactivitiesandservices. Human resources are of course the key to any intervention at community level or by community based organisationsand networks. It is important to note that communities themselves provide human resources, skills and knowledge and often contribute funds, effort and materials to community programmes and interventions. For example: community knowledge and experience contributions to planning and implementation processes, providing places to meet, food, incomegenerating activities, or assisting communitymembersingainingaccesstoservices. Fundingforcoreorganisationalcostsandforcapacitybuildingarealsovitalforcommunityactorsinorderto enable them to provide sustainable and effective responses, as well as funding for implementation of programmes and interventions. It is essential also to include funding for infrastructure items and services, informationsystems,andsystemsforsourcingandmanagingessential.

3.1 HUMANRESOURCES:SKILLSBUILDINGFORSERVICEDELIVERY,ADVOCACYANDLEADERSHIP
Development of human capacity is important for community leadership and progress towards community health goals. People are the central resource for community organisations and groups, including employees and volunteers and members of community groups and networks. In communities,therearealsoindividualswhoprovideadviceandguidance;actasinfluencers,enable

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access to certain sectors of the community; and contribute to activities such as fundraising, or supportingindividualsandfamilies.Recruitment,retentionandmanagementofhumanresourcesare key aspects of organisational strengthening and leadership for advocacy, but it is also essential to ensure that technical skills and experience are given high priority in order to assure programme quality, achieve timely progress towards defined goals and build the evidence base for effective community contributions to health. The technical capacity of community actors is becoming increasinglyimportantascombinedstrengtheningofhealthandcommunitysystemsandintegrated service delivery is prioritised in order to reach the Millennium Development Goals (MDGs), for exampleinTB/HIVintegration,sexual&reproductivehealthandprimarycareincommunities.

SDA4:SKILLSBUILDINGFORSERVICEDELIVERY,ADVOCACY&LEADERSHIP
Rationale:Skillsbuildingforservicedeliveryincludesorganisationalskillsandmanagementtoensure timelyandefficientoperationalsupportforservices.Technicalcapacityofcommunityactorsneedsto bebuiltsothattheycandevelopanddelivereffectivecommunitybasedservicesandcanensurethat communitiesarewellinformedandsupportedforaccesstoservices,referrals,followup,adherence etc.Thisalsoneedstobebackedupwithtechnicalskillsfordocumentingexperiencesandengagingin communityresearchmethodologiestodeterminewhatworksbestforcommunities.Individualswith capacityforleadershipwillalsoneedtogainskillssuchasnegotiation,multistakeholderworkingand public speaking. Community actors also need to have appropriate understanding of human rights, especially for key affected populations. Capacity building will be needed to ensure that they understandcommunityhealth,socialandotherchallengesandthattheyareabletounderstandand makeeffectiveuseofinterventionsdesignedtoimprovepeopleshealthknowledgeandbehaviours andtheiraccesstoanduseofservices. Examplesofactivities: Technicalcapacitybuildingforhealthsupportrolestreatmentadherence,peercounselling,HIV counsellingandtesting,DOTS,malariaprevention,newborn&childhealth,nutritionetc; Developmentandimplementationofreferralandsupportnetworksandsystems; Planningforcontinuousimprovementofqualityservicesthroughmentoring,updatingofskills andinformationandregularreviewsofserviceavailability,useandquality; Traininginspecialtechnicalareassuchaschildprotection,socialprotection,workingwith criminalisedormarginalisedcommunities,providingintegratedTB/HIVservices,drugresistance, communityauditssuchasverbalautopsyofreasonsfordeathsetc; Documentationanddisseminationofgoodpracticeexamples; BuildingnewtechnicalcapacitiestoenhancethedeliveryofintegratedservicessuchasTB/HIV, SRH,comprehensivePMTCT,maternalandchildhealthandprotection; Capacitybuildingonappropriateresearchmethodse.g.operationalresearchmethodologies; Capacityandskillsbuildingtoenablepersonneltoworkeffectively,safelyandethically; Mentorshipforprovidingqualitytechnicalsupport; Developmentoflinkagesandprogrammesfortrainingandsupervisorysupportbyregional networksornationalbodies; Planningforcontinuingskillsdevelopmentandreview,forexample:seminarsandmeetings; accesstouptodateinformation;professionalandmentoringsupport;strengthening professionalnetworkse.g.forcounsellors,TBoutreachworkers,malariapreventioneducators; Developmentofcommunication,participationandleadershipskillsforworkingwithcommunities andindividualsandimplementinglocaladvocacyinitiatives; Capacitybuildingonuseofnewandtraditionalcommunicationtechnologiesforadvocacyand servicedelivery(e.g.adherencesupport,followup); Trainingoftrainersonchallengingstigma,discriminationandharmfulsocioculturalpractices; Advocacyonlegalandpolicyframeworkse.g.decriminalisationofbehavioursormarginalised groups;developmentandenforcementofchildprotectionpolicies;

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Trainingforcommunityactorsandstakeholdersinpartnershipbuildingandcollaborative approachestopolicyandadvocacywork; Leadershiptrainingforpolicyandadvocacyrolesandcommunityrepresentationatnational levels; Increasingcommunityactorknowledgeofpolicyissuesandbroadersocial,cultural,politicaland economicdeterminantsofhealth; Developingdocumentation,reportinganddisseminationskills.

3.2 FINANCIALRESOURCES
CSS must include adequate and sustainable funding for community actors, especially CBOs. This includesbothprojectfundsforspecificoperationalactivitiesandservicesand,crucially,corefunding to ensure organisational stability as a platform for operations and for networking, partnership and coordinationwithothers.Itisessentialthatcommunityactorshavetheappropriatefinancingandthe financial management skills.30 Community organisations are most often unsuccessful in mobilising corefundingthatisunrestrictedthatis,nottiedtoaspecificprojectorinterventionandaimedat support for an organisations basic running costs. However, when based on agreed contractual arrangements, such as a memorandum of understanding and financial reporting to funders, core funding contributes greatly to sustainability. It ensures continuity and allows organisations to have the appropriate paid staff, supplies and infrastructure to build up their programmes in response to theneedsofthecommunitiestheyserve. Organisations may need guidance and technical support to identify sources of funding, develop relationships with funders and successfully meet their criteria. They will need to develop their financial systems and manage them efficiently, transparently and sustainably. The same applies to organisationsundergoingexpansionduetoscalingupofactivitiesorservicesandincreasedfunding. Different funders apply different rules and reporting requirements and support will be needed to enable organisations to deal with this without being distracted from programmematic work by increased administrative demands. Good management of finances is essential for organisational supportandservicedelivery,anditisalsoanessentialfordemonstratinggoodstewardshipoffunding from donors, governments and communities, which is important for sustainability and mobilising furtherresources.31

SDA5:FINANCIALRESOURCES
Rationale:ThisSDAconcernssupportforbettermobilisation,managementandeffectivenessof financialresources.Thissupportisrequiredinordertoenableactorstoplanforandachieve predictabilityoffinancialresourcesforstartup,implementation,scaleupandlongerterm sustainabilityofcommunityinterventions,andworksuccessfullytowardsimprovedoutcomesand impacts.Itincludesidentifyingandleveragingexistingsourcesoffinance(andstaffing)butwithout engaginginunduecompetitionwithotheractors. Examplesofactivities: AssessingtheleveloffundingrequiredforCSSandservicedelivery; AdvocacyforCSSfundingfromgovernmentsanddonors;

30

FundingforcivilsocietyresponsestoHIV/AIDSinTanzania:Status,problems,possibilities;CADREMay2008 http://www.cadre.org.za/node/192

31

ModelsforFundingandCoordinatingCommunityLevelResponsestoHIV/AIDS;CADRE2007 http://www.cadre.org.za/node/198

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Hiring,training,supervisionandmentoringofresourcemobilisationstaff; Planningforfundingbasedonorganisationsaldevelopmentandprogrammematicneeds identifiedbymembersandsupporters; Proposalwriting,accountingforandplanningactivities; Capacitybuildingforfinancialmanagement,bookkeeping,accounting,reporting,useofbank accounts,acquisitionanduseofaccountingsoftwareetc; Capacitybuildingonoversightofresourcesandbudgets,designandimplementationofinternal accountabilitysystems; Hiringexternalauditorstosupportaccountabilitytocommunitiesandfunders; Capacitybuildingonresourcemobilisation,includingleveragingexistingresourceswithout creatingcompetitionacrossvariousprojectsorgeographicalareasandtheroleofpoliciesand processesrelatingtoglobalhealthinitiatives(GHIs); Developmentandmanagementofsmallgrantschemesforcommunities,includingcoresupport suchassocialtransfersforvulnerablepeople,socialwelfareservices,childprotectionandhealth relatedincomegeneratingactivities; Developmentandmanagementofschemesforremuneratingcommunityoutreachworkersand volunteersorprovidingotherincentivesandincomegenerationsupport.

3.3 MATERIALRESOURCESINFRASTRUCTURE,INFORMATIONANDESSENTIALCOMMODITIES
Manyorganisationslackcapacityindealingwithmaterialresourcesinfrastructure,information,and essentialcommodities(includingmedicalandotherproductsandtechnologies).Theyrequirefunding and technical support in order to develop and operate reliable and sustainable systems for these, basedonstandardsalreadydevelopedandwidelyavailable. Infrastructure includes such things as office space; utilities (water, power, waste); transport; communications and information management systems; maintenance & repair of building and equipment.Ensuringtheviabilityandadequacyofinfrastructureisessentialfailuretoachievethis canhavecatastrophiceffectsonactivitiesandservices. Informationincludesaccesstoinformationmaterialsinappropriateformatsandlanguages,systems for storing and retrieving as part of an overall knowledge management system. Community actors need funding for organisational information systems accounting, management etc, M&E information, and technical information for design, management and delivery of activities and services.Thislatterareaisoftenneglected,causingimplementerstoworkwithoutdatedinformation, risking weaknesses and inappropriate activities in their interventions. Support will be required to ensure that information is properly recorded, stored, updated and communicated so that implementers, the community, stakeholders and partners can share knowledge for future planning anddecisionmakingandforpolicydialogueandadvocacy. Essential commodities of good quality need to be available in the right quantities and at the right times to contribute to the continuity, credibility and effectiveness of activities and services. This includes: office equipment & supplies; communication materials; utilities & building maintenance; fuelfortransport;medicalproductsandtechnologiesforprevention,treatmentandcare(condoms, bed nets, medicines, lab equipment etc.), safety equipment (universal precautions) for community healthworkers,homecareworkers,teachersetc.

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SDA6:MATERIALRESOURCESINFRASTRUCTURE,INFORMATIONANDESSENTIALCOMMODITIES (INCLUDINGMEDICALANDOTHERPRODUCTSANDTECHNOLOGIES).
Rationale:ThisSDAfocusesoncapacitiesbyallactorsfor:forecasting,quantification,sourcing, managementandappropriateuseofmaterials.Materialsincludeallnecessaryorganisational infrastructureitemsandsupplies,andanyitemsneededforoperationalactivitiesandservice delivery,includingtransportandofficeessentials,forexample.Essentialcommoditiesrangefrom simplestationeryitemssuchasnotepadsandpencilsthroughcampaignandinformationmaterialsto medicines,dressings,bednetsandcondoms.Someactorsandinterventionsmayhavelimitedneeds formaterialresourcesandwillonlyneedverysimplesystemsfordealingwiththem.Moredeveloped systemswillbeneedediflargequantitiesandexpendituresareinvolvedandtherewillneedtobe greaterattentiontomanagement,maintenanceandsecurityofsuchsupplies.However,thebasic principlesofmanagingmaterialresourcesarethesame,whateverthesizeofthesystem.32 Examplesofactivities: Developmentandmanagementofsystemsforcalculatingneedsandmonitoringusageof materialresources; Selectionofappropriatemethodologiesforreplenishingsuppliesaccordingtosizeoforganisation andprogrammematiccontext; Physicalinfrastructuredevelopment,includingobtainingandretainingofficespaceand equipment,improvingcommunicationstechnology,provisionandmaintenanceoftransport; Traininginskills,goodpracticeandqualitystandardsforsourcing,procurementandsupplyof consumables(especiallymedicinesandhealthgoods); Traininginskills,goodpracticeandstandardsforensuringgoodqualityofinfrastructure materialsandessentialcommodities,includingsupplierselection,storage&distribution, preventivemaintenanceofbuildings,computers,officeequipmentandtransport; Planning,managementsystemsandprovisionofessentialmedicalandothersuppliesforservice deliverysuchasmedicines,labreagents,syringes,needles,condomsandotherconsumables,X raymachines,microscopesetc; Developingandimplementingsystemstoroutinelyrecordcommunityexperiencesand disseminategoodpracticesandlessonslearned; Developingappropriatecommunitylevelinformationandknowledgemanagementsystems; Establishinginformationcentresandonlineinformationaccesssystems; Packagingofinformationandlessonslearnedtodisseminateasevidenceofgoodpractices; Trainingandmentoringininformationmanagement(paperbasedorcomputerbased); Trainingandmentoringinuseofinformationandcommunicationtechnologies.

32

PSM(procurement&supplymanagement)resourcesareaccessibleat:http://www.psmtoolbox.org/en/

Handbookofsupplymanagementatfirstlevelhealthcarefacilitieshttp://www.who.int/hiv/amds/HandbookFeb2007.pdf ManagingTBmedicinesattheprimarylevelhttp://erc.msh.org/toolkit/toolkitfiles/file/TBPrimaryLevelGuideApril 2008_finalEnglish.pdf Guidelinesforthestorageofessentialmedicinesandotherhealthcommodities http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/GuidStorEsse_Pock.pdf

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CORECOMPONENT4:COMMUNITYACTIVITIESANDSERVICES
Community activities and services are essential for achieving improved health outcomes and they are thereforeanessentialandintegralcomponentofcommunitysystemsstrengthening.Learningbydoingisan importantcapacitybuildingprincipleofandisespeciallyapplicabletosystemsforservicedeliveryandsupport at communitylevel. Quality community programmes, activities and services that areevidenceinformed and cost efficient will build on existing systems and services and contribute to creation of demand for services, social behaviour change, increased health and reduced disease transmission in the community. Community basedorganisationsandmembersofkeyaffectedcommunitiesareinauniquepositiontoassessandaddress the needs of their own people. This is especially true for marginalised people who are criminalized and/or stigmatized and who therefore often avoid state services. This brings greater credibility and relevance to communityservicedeliverysystemsandaddsstrengthtoleadershipandadvocacy.Itisthereforeessentialto provide support to community actors for building and strengthening community systems to deliver services andtosupportcommunitiestousethoseservices. A quality approach should underlie the design and implementation of community service delivery systems, fromsituationassessmentandinterventiondesignrightthroughtodeliveryandassessmentofoutcomesand impacts. This depends on having a sound basis of informed management and technical skills and ability to utilise evidence of what works. Systems for service delivery should also be implemented ethically and sustainablybypeoplewhoareappropriatelyskilledandknowledgeable.Systemsshouldbebasedonaccepted nationalorotherstandardsofpracticewheretheyexistandshouldbelinkedwithnationalhealth,socialcare and M&E systems and standards. It may be necessary for community actors to advocate for and initiate development of new practice standards if none exist already. Adaptability of services is important for responding to changes in institutional capacity and resources, in patterns of disease or new knowledge on prevention,careandsupport,ortochangingdemographicsandpoliticalorsocialenvironments.33 Therearemanyinterventions,particularlysupportactivitiesforcommunitymembersaccessinghealthrelated services at community level, that may fail to acquire funding because of differing views on whether theyfit withincommunitysystemsorhealthsystems.Itisimportantnottolosesightofthefactthat,whereverthey fit, they are essential services for people in need. Delivery through community systems may be the most effective and acceptable to a community even for interventions clearly related to health. Many community basedprogrammesaremovingtowardsintegrateddeliveryofservicesthesamepersononthesamedaymay deliver both health and nonhealth interventions for a range of health and other challenges. It is therefore logical that funding and monitoring should also be integrated for the community actors responsible for delivery. Funding for research should also focus on the added value that such services and activities can provide,ensuringbetterplanning,implementationandqualityimprovementbasedonvalidatedevidence.
33

StrengtheningCommunityHealthSystems:Perceptionsandresponsestochangingcommunityneeds;CADRE2007. http://www.cadre.org.za/node/197

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SDA7:SERVICEAVAILABILITY,USEANDQUALITY
Rationale:Wellplannedandimplementedcommunitybasedservicescandelivereffective,safe,highquality andaccessibleinterventionsonanequitablebasistothosewhoneedthem,forexampleprevention,careand treatmentofHIV,TBandmalaria.Theywillalsodeliverinterventionsaimedatmitigatingtheeffectsof diseasesonindividualsandcommunities,includingcareandsupportofchildrenandothervulnerablepeople, suchaspeoplewhousedrugs,pregnantwomenandprisoners.Access,equityandquality,alongwithrights basedprogrammemingandharmreduction,arekeyconceptsinthedeliveryofcommunitybasedservices.It mustbeensuredthatnationalguidelinesforkeycommunityactivitiesandservicesaredevelopedinorderto ensurethatminimumstandardsforqualityaremet,whilealsorecognizingthatnotallcommunityactivities willbeincludedinasetofnationalstandards.Communitysystemsthereforeneedtobestrengthenednotonly toplanandprovideservicesbutalsotoimplementanddevelopstandardsandprotocols,providesupportive supervision,andensurecontinuousqualityimprovement.Functionalandefficientsystemsarethereforevital fordeliveryofthesecommunitybasedinterventionsincludingandcommunityactorswillneedappropriate supportandtechnicalassistancetoidentifywhatsystemsareinplaceorneededinordertofillgaps,andto developsystemsthatmaximiseuseofresourcesanddeliverqualityservicestotargetpopulations.Theywill alsoneedtodevelopthetechnicalcapacitytoimplementexistingnationalorotherstandardsandtoadapt themordevelopnewstandardswherenewapproachesandactivitiesarebeingimplemented.Systemsfor supportivementoringandsupervisionwillalsobeneededinordertoensurecontinuingqualityinservice delivery. Examplesofactivities: Mappingofcommunityhealthandsocialsupportservicesandtheiraccessibilitytoendusers; Identification, ensuring availability and implementation of national or other relevant guidelines for deliveringqualityservices; Identification of services and activities where good practice standards are not available or need to be adapted, and developing strategies to address such gaps in ways appropriate to community service deliveryandsystems; Mappingofavailableknowledgeandanalysinginformationsources,flowsofinformationandgapsthat needtobeaddressedtoimprovedecisionmakingandimplementationsatnational,localandcommunity levels; Developingandusingknowledgemanagementsystems,includinginformationcentres,inordertoshare experienceandgoodpracticeandinformplanningandimplementationofqualityservicedelivery; Identificationofpopulationsmostatriskandmostinneedofservices; Identificationofobstaclestoaccessingandusingavailableservices; Participatory development and implementation of referral systems to ensure access to and use of services,andrereferraltocommunitysystemsforongoingsupport; Planningforcommunitybasedservicedeliverybasedonmappingandanalysisofneedsandgaps; Planning for continuous improvement of quality services through mentoring, updating of skills and informationandregularreviewsofserviceavailability,useandquality; Development of integrated service delivery systems to address the range of health, social and related needs in communities, for example: comprehensive homebased care systems, counselling and psychologicalsupportsystems,includingpeerledcounsellingandselfsupportgroups;social,familyand economic support systems; systems to provide support to individuals for service use and followup, includingaccompaniment,translation,locatingandaccessingfurtherservices; Developmentofcommunitysupportcentresprovidingarangeofservicessuchasinformation,testing& counselling,referrals,peersupport,outreachtokeyaffectedpeopleandcommunities,legalsupportetc; Developmentofsystemstocreatedemandforimprovedaccesstoanduseofhealth,socialwelfare,legal and other services and advancing the health and other rights of key affected populations, including community treatment and health literacy campaigns and community education to prevent stigma and discrimination; Developmentofpeereducationandcommunityoutreachprogrammestosupportkeypopulationsatrisk, especiallyexcludedandvulnerablepopulations.

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CORECOMPONENT5:ORGANISATIONALANDLEADERSHIPSTRENGTHENING
Organisationalstrengtheningisakeyarea,aimingtobuildthecapacityofcommunityactorstooperateand managethecoreprocessesthatsupporttheiractivitiesdevelopingandmanagingprogrammes,systemsand services effectively; ensuring accountability to their communities, stakeholders and partners; and providing leadershipforimprovingtheenablingenvironmentinordertoachievebetterhealthoutcomes.Keyknowledge and skills in this area would include, for example, leadership in representing the vision and goals of the organisationexternallyandinternally,developmentofsystemsofaccountabilityandparticipationindecision making,managementofworkersandrespectforemploymentrightsandlaws. Thereisparticularneedtostrengthensupportandfundingfornetworksandsmallorganisationsatcommunity level,suchasthoseofpeoplelivingwithandaffectedbyHIVorotherkeyhealthproblems.Fundinghasinthe past been limited mainly to specific projects, advocacy and profileraising opportunities and there has been little support for developing organisational capacity or increasing knowledge and skills for a wider health supportrole.Thispatternneedstochange,inordertostrengthentheeffectivenessofcommunitysystems.In somecountriestheremaybemorethanonenetworkinexistence,ortheremaybeseveralstrongnetworks, CBOsorNGOsworkinginthesamefield,andtheymayneedsupporttoworktogethertoavoidduplicationof activitiesandpromotejointplanninganddecisionmaking. Accountabilityisanimportantaspectofstrengtheningorganisations,assuringcommunities,stakeholdersand partners that there is good stewardship of the organisationss resources. Mechanisms for independent oversight and guidance may be needed to demonstrate this, for example: meetings with stakeholders and communitymembers;independentauditsoffinancesandevaluations;openaccesstoinformationandreports for stakeholders, community members and funders on a regular basis. Community organisations that hold themselvesaccountabletotheircommunitieswillalsobuildtheircapacitytoengageinadvocacyforgreater transparencyandaccountabilityofpublicbodiesandgovernmentstocommunities.

SDA8:MANAGEMENT,ACCOUNTABILITYANDLEADERSHIP
Rationale:Resourcesandtechnicalsupportmaybeneededtobuildthecapacityoforganisationstosupport deliveryoftheproposedrangeandqualityofactivitiesandservices.Thisincludescapacityforlongterm strategicplanning,management,sustainability,scalingupandrespondingtochangethroughdevelopmentof organisationsalsystemsandthecapacityforstrategicplanning,monitoringandevaluation,andinformation management. Examplesofactivities: Organisationalcapacityassessment; Organisationsal/managementsupportandtrainingforsmallandnewNGOs/CBOs; Developingcapacityfornegotiatingandenteringintoagreementsandcontractualarrangementssuchas memorandaofunderstanding,termsofreference,supplycontractsetc; Developingcapacityandplansforhumanresourcerecruitmentincludingfortechnicalsupportsystems andorganisationalneeds; Developmentofplansformanagingandbuildingcapacityofhumanresources,includingjobdescriptions, careerdevelopmentplans,staffhandbooksetc.inordertosupportandretainstaffandvolunteers; Developmentofkeyskills,forexample:writingofficialreports,letters,proposalsetc; Systemsfortraining,mentoringandexperiencesharingforleadership,organisationsaldevelopment, managementandaccountability; Regularisationoflegalstatus(whenappropriate)andauthoritytoenterintoagreements(forexample, openingbankaccounts,buildingleases,purchasingproperty);

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Increasingtransparencyandaccountabilitythroughmeetingswithstakeholdersandcommunitymembers; independentauditsoffinancesandevaluations;openaccesstoinformationandreportsforstakeholders, communitymembersandfundersonaregularbasis; Trainingandongoingmentoringandsupervisionforprogrammeandinformationmanagement; Developingcapacityforprojectdesignandstrategicplanning,projectcyclemanagement; Supportinmakingbusinessplanstobecomeselfsustainable(managementtraining); Recruitment,management&remunerationofstaff,communityworkersandvolunteers; Newslettersforinternalcirculationtokeepstaffinformed;creatingsharedvision; Communicationofsharedvisionamongtheorganisationsandsustainingmotivation; Strengtheningcommunityleadership,includingsharedleadership; Capacitybuildingsystems.

CORECOMPONENT6:MONITORING&EVALUATIONANDPLANNING
Communityled M&E is essential forcommunity systems. It will provide the strategic informationneeded to make good decisions for planning, managing and improving programmes, and for formulating policy and advocacy messages. It also provides data to satisfy accountability requirements. Communityled M&E will make effective use of data provided by community members, These include data from qualitative and participatory methodologies, such as action research, operational research, focus groups and key informant interviews,aswellasdatafromregularmonitoringofoperationalinputsandoutputsandinternalorexternal evaluations. This means that both qualitative and quantitative indicators are needed, that community level M&Emethodologiesareessential,andthatfeedbackmechanismsmustroutinelybeusedtoallowcommunity organisationsandcommunitymemberstouseM&Eresultsforreflectionandfurtherplanningandaction.3435 Data collection and analysis should also follow a gender and agerelated approach in order to better understandthedifferentvulnerabilitiesandneedsofwomenandgirls,menandboysandtransgenderpeople. For example, gender norms affect womens and mens risks of exposure to mosquitoes and malaria, due to divisionsoflabour,leisurepatternsandsleepingarrangements.Thisalsoaffectstreatmentseekingbehaviours andhouseholddecisionmaking,resourceallocationandfinancialauthority.36 The first steps for building or strengthening community systems are also essential for building a meaningful M&Esystem:definitionoftargetgroupsandareas;stakeholderidentificationandconsultation;assessmentof needsandanalysisofgapsandavailableresources.Thiswillinformdiscussionaboutwhatcanrealisticallybe done to fill the gaps, who should be involved and how to make it happen, based on clear and achievable objectives. During implementation, regular review of implementation will help in analysing progress and answeringkeyquestionssuchas:arewedoingtherightthings?,arewedoingtherightthingswell?,are wedoingenoughoftherightthings?,haveourinterventionsmadeadifference?andhowdoweknow?37
34

TheMostSignificantChange(MSC)Techniqueaguidetoitsuse;RDavies&JDart2005 http://www.mande.co.uk/docs/MSCGuide.pdf SelfAssessmenttoolsonHIV,malariaandothercommunityissues;TheConstellation2008 http://www.communitylifecompetence.org/en/94resources

35

36

Gender,HealthandMalaria;WHO&RBMJune2007; http://www.rollbackmalaria.org/globaladvocacy/docs/WHOinfosheet.pdf Ifyoudonotmeasureresults,youcannottellsuccessfromfailure;ifyoucannotseesuccess,youcannotrewardit;ifyou cannotrewardsuccess,youareprobablyrewardingfailure;ifyoucannotseesuccess,youcannotlearnfromit;ifyou cannotrecognizefailure,youcannotcorrectit;ifyoucandemonstrateresults,youcanwinpublicsupport.Citedonthe WorldBankGAMETsiteathttp://gametlibrary.worldbank.org/pages/12_1)HIVM_ESystems12components_English.asp

37

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Forexample,afocusgroupdiscussionamonginjectingdrugusersmightrevealthataneedleexchangeservice wouldhavemoreimpactbydistributingsyringesofasizepreferredbydrugusers,afactthatwouldnotbe detected in quantitative data on the number of syringes distributed. Evidence of the effectiveness of a changed approach could be validated through the design and implementation of an operational research project,thusaddingsignificantnewdatatotheexistingevidencebase. An effective communitylevel M&E plan provides a structure for collecting, analysing, understanding and communicatingkeyinformationthroughoutthelifeofaninterventionorprogramme.Theplanshouldcover thewiderangeofactionsandprocesses,fromgatheringinformationforplanningactivitiesandinterventions, throughdesigningandimplementingworkplans,reviewingprogressandevaluatingwhathasbeendoneand communicating results to implementers, communities, stakeholders and funding partners. It is highly recommended that community M&E systems should be aligned with the national health and social welfare M&E systems and with the legal and policy environment. This will ensure that reporting to national level contributestonationaldataandisalsoincorporatedintothelocalsystemwithoutcreatingextraburdensof datacollectionandanalysis. Itisalsoessentialtobuildupsystemsforcommunitylevelknowledgemanagement.Thisincludesdatafrom theM&Esystemandfromformalandexperientialresearch,basedontheexperiencesofcommunitiesandkey affectedpopulations.Agoodknowledgemanagementsystemwillenablecommunityactorsandkeyaffected populations to establish evidence of what works and does not work at community level so that they can respondeffectivelytopolitical,socialandeconomicchallengesandaddressbehaviours,rightsviolationsand other factors that drive the need for improvements in health and social care and the surrounding environments.Itwillalsoprovidecommunitymemberswithaccesstonews,informationongoodpractices, information on available tools and technical assistance opportunities, information about policy and opportunitiestoengageinpolicydialogueandnetworkwitheachother.It

SDA9:MONITORING&EVALUATION,EVIDENCEBUILDING
Rationale: Community organisations often have limited human and material resources for building and operating M&E systems. They lack training in M&E, and can be seriously overburdened because of multiple reportingrequirements,highstaffturnover,unreliableelectricityandlimitedinfrastructuresuchascomputers orotherequipment.Muchworkalsoneedstobedone,intermsofsupervisionandplannedtraining,toputin placeeffectivesystemstostrengthenM&Ecapacityatthecommunitylevel.Forexample,animportantstep wouldbetoincreasesupportfromthenationallevelforsystematicinvolvementofCSOsinnationalstrategies. Currently many community organisations are registered with departments other than health, which makes integrationintohealthM&Edifficult.Muchworkremainstobedonetoensurethatallactorsworktogetherin integratednationaldiseaseprogrammes. LargerorganisationsmayalreadybefamiliarwithM&Eprocessesbutlacksufficientcapacity;smallergroups andorganisationsmaybeunfamiliarwiththemandwillneedongoingsupporttodevelopandimplementM&E successfully.38 Existing actors, systems and resources need to be clearly identified in order to correctly plan andtargetinterventions,aimingataddedvalueandavoidingunnecessaryduplicationofeffortsandactivities.
38

TherearemanyguidestoM&EandProjectManagement;ahighlydevelopedguidecanbefoundat http://gametlibrary.worldbank.org/pages/25_Introduction_Background_English.asp; asimpleguideaimedatsmallercommunityactorsandCSOscanbefoundat http://www.coreinitiative.org/Resources/Publications/ProjectCycleManagementToolkit.pdf

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This will include having up to date information on what works for specific populations and communities in ordertomakenewinterventionsasevidenceinformedaspossible. Where formal evidence for interventions is lacking, it will be important to include research within implementationplans,forexampleoperationsresearch,inordertostrengthentheevidencebase.Community knowledgemanagementcontributestoevidencebuildingandaccesstokeyinformation.Itenablesthesharing ofcommunityknowledgebothwithincommunitiesandwithawiderrangeofstakeholders.Itcontributesto translatingknowledgeintopolicyandaction,tosharingandapplyingknowledgebasedonexperiencebothat local level and with policy and programme decision makers at national, regional and international levels. Communityorganisationswillneedfundingforknowledgemanagementactivitiessuchasthedevelopmentof communicationplatforms;gathering,collatinganddisseminatinggoodpracticesandusefultools;makinguse ofopportunitiestopromotenetworkingandthedevelopmentofcommunitiesofgoodpractice. Examplesofactivities: RecruitmentofM&Estaff/ensuringstaffcapacitytoimplementM&Eactivities; Orientationofcommunitygroups,stakeholdersandstaffatstartofprogrammetoensuretheirbuyinand participationinsituationanalysis; Capacitybuildinginanalysisofcommunitysituations,sourcesofvulnerability,resources,strategic partners,gapsandobstaclestoaccessingandusingavailableservices; Capacitybuildingonrights,participationandprotectionforworkingwithchildrenandothervulnerable adultsandyouth,forexampleinperformingsituationanalysis,collectingqualitativedataonoutcomes, documentatingexperiencesetc; Communitymonitoringandevaluationofservicequality,includinglinkageandreferralsystems,and clinicalservices;39 Training,mentoringandsupervisionformonitoringandevaluation,includingdevelopmentanduseof simpletousestandardizedrecords&registersforessentialdata; Developingcapacityfordesignandimplementationofdatacollection,serviceuserinterviews,desktop reviews; Developingcapacityforanalysingdata,andidentifyinganddocumentingkeyinformationandlessons learned; Traininginanalysisanduseofavailabledatasuchassurveysofkeyaffectedpopulations; Useofparticipatoryresearchmethodologiessuchasactionresearch,operationalresearch,useoffocus groups,interviewsetc; ExchangevisitsandpeertopeerlearningandsupportoncommunityM&E.

39

Seeforexample:OperationsManualforDeliveryofHIVPrevention,CareandTreatmentatPrimaryHealthCentresin HighPrevalence,ResourceConstrainedSettingsespeciallyChapters4&6;WHOIMAITeamDec2008; http://www.who.int/hiv/pub/imai/operations_manual/en/

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SDA10:STRATEGICANDOPERATIONALPLANNING
Rationale:Assessmentofneedsandanalysisofgapsandavailableresourcesatcommunitylevelareessential firststepsforcommunityactors.Communityneedsandresourcesvarybetweencommunitiesandamongkey affectedpopulations,forexampledrugusers,sexworkers,olderpeople.Existinginformationsourcesneedto be researched in order to link community assessment findings with national plans and strategies, with available guidance for interventions andwith researchthatprovidessupporting evidence foraddressing the needsandgapsthatarefoundtoexist. Strategicplanninghelpstoclarifywhatistobedone,whyitisbeingdone,whatarethegoalsandwhatkey activitiesandresourceswillberequiredtoachievethegoals.Anoperationalplanorworkplanisimportantfor communityplanning,isbasedonastrategicplanandprovidesspecificdetails,timelinesandbudgetsfor implementationofactivitiesandprogrammes.Clearly,theseplanningprocessesdependonhavingavailable sufficientandaccurateinformationaboutthecommunitytobeserved,thenationalandlocalcontextsin whichwillinterventionswillhappen,theresourcesavailableandsoon.Effectiveplanningshouldalwaysbe basedonprioranalysisandinformationgathering. Smallgroupsandorganisationsmayuseasimplifiedapproachforstrategicplanning,butthestepsrequired areverysimilarwhateverthesizeoforganisation.Firstly,itisimportanttodecidehowtheprocesswillwork whowillbeinvolved,howdecisionswillbemade,andwhattimescaletofollowinordertofinalisetheplan. Thenthereneedstobeconsensusonwhatisimportanttotheorganisationandwhatitwantstoachievefor thecommunityitsvaluesandcommunityvisionforexample,equalityforwomenandgirlsora communityinwhichnoonediesofmalaria.Thisconsensuswillenablethegroupororganisationtodefineits missionthecontributionitaimstomaketothecommunityandspecificgoalsandtargetstoachievethis.It willthenpossibletostartanalysingandcostingresourcesandplanatimescaleforimplementation. Evidencebasedoperationalplansforimplementation,basedonthestrategicplan,willincludeactivitiesand budgetsfordefinedperiods,forexampletwelveorsixmonthsatatime.Otherplansshouldalsobedeveloped fromanearlystagetosupporttheorganisationandprogrammeimplementation,forexampleplansfor managementandhumanresources,monitoring&evaluation,operationsresearchanddocumentationofgood practice,resourcemobilisation,procurementandsupplymanagement,strategiccommunications,technical assistanceandcapacitybuilding. Examplesofactivities: Assessmentofservicegaps; Assessmentofwhatpersonnelwillbeneededforinterventions,whatattributes,capacitiesandskillsthey needtohave,andwhatresourceswillbeneededtosupportthem; Mappingofhealthandsocialsupportactorsandservices,serviceprovidersandnetworksand understandingtheirrolesinthetargetcommunity; Reviewandsharingofnationalplans,strategiesandpoliciesrelevanttoproposedactivitiesand communities; DevelopingcommunitylevelM&Eandoperationalplans,includingreportingsystems,regularsupervision, mentoringandfeedbacktocommunityactorsandstakeholders; Capacitybuildingonparticipatinginandunderstandingresearchaffectingcommunities,andputting relevantresearchfindingsintopractice; Identificationanddevelopmentofplansforcapacitybuildingandtechnicalassistance; Developmentoforganisationalandtechnicalcapacitybuildingplans; Developmentofplansforregularreportingandcommunicationtogovernment,stakeholders,community andpartners; Orientationforprogrammestaffonprogrammevision,objectives,plansandpoliciesatstartof programmeandwhennewstaff/volunteerscommencework;

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Trainingandsupportfordevelopmentofcommunityactorsstrategicandoperationalplans,linkedto nationalstrategiesandplans.

4. CSSINTHECONTEXTOFTHEGLOBALFUND
TheGlobalFundencouragesapplicantstoincludeCSSinterventionsroutinelyinproposalswhereverrelevant for improving health outcomes. The proposal form and guidelines have been revised in 2010 to reflect the increasedimportanceofCSSwithinproposalstotheGlobalFund. In preparation for completing the proposal form, applicants will need to work closely with community organisationsandactorstoidentifywhichcommunitysystemstrengtheninginterventionsneedtobefunded, based on analysis of existing resources and the gaps and weaknesses that need to be addressed. It is also important to show clearly how systems will be strengthened by interventions and thus ensure that CSS fundingwillbeappropriatelytargeted. Applicants are encouraged to consider CSS as an integral part of assessments of disease programmes and healthsystems,ensuringthattheyidentifythoseareaswherefullinvolvementofthecommunityisneededto improvea)thescopeandqualityofservicedelivery,particularlyforthosehardesttoreach,b)thescopeand quality of interventions to create and sustain an enabling environment, and c) evidencebased policies, planningandimplementation. Applicants may include CSSrelated interventions in their diseasespecific proposal or under the HSS cross cuttingsectionoftheproposalform.ThesetofCSSinterventionsthatareincludedinanHIV,TBorMalaria proposal should focus both on the specific disease being applied for, but should also include general communitysystemsstrengtheninginterventionsasfaraspossible. It is important to focus on aspects related to strengthening community systems in the context of service delivery, advocacy and enabling environment for the three diseases. Because CSS particularly focuses on affected communities, CSS interventions should be harmonized across the three disease components wheneverpossibleandoverlapshouldbecarefullyavoided.ThismeansthatHIV,TBandmalariaprogrammes needtocoordinatetheirefforts,avoidduplicationandensurethatCSSinterventionsforthedifferentdiseases arecomplementarytoeachotheratcommunitylevel.Secondly,sincetheGlobalFundusesaperformance basedfundingsystemitisimportantthatalimitednumberofindicatorsarecarefullychosenasabasisfor regularreportingtoinformdisbursementdecisions.Beforeandduringtheproposaldevelopmentprocessthe followingstepsshouldbeundertaken: Createanenablingenvironmentfortheparticipationofallstakeholders(representationofthe differentstakeholdersinvolvedinthenationalresponse,particularlythemostatriskpopulations); ReflectcriticallyinadvanceoftheannouncementofaGlobalFundRoundonwhichoftheidentified gapsandconstraintsaproposalforfundingshouldbedevelopedfor,theimplementationmodelor strategy,thecharacteristicsofpotentialbeneficiaries,andthecomponent(HIV/AIDS,TB,malariaor HSS); ReadtheGlobalFundProposalFormandGuidelinesthoroughlyandconsiderineverypartofthe proposalhowcommunitiescanbestrengthened; ReadallrelevantGlobalFundInformationNoteswhichcanbefoundonthewebsiteoftheGlobal Fund:www.theglobalfund.org Gathertogetherallrelevantexperts,stakeholdersandsectorsanddetermineasystembywhicheach canengageinproposaldevelopment(eitherthroughaproposaldevelopmentcommittee,technical workinggroupsorthroughorganizedconsultations).40

40

SupportingcommunitybasedresponsestoAIDS:AguidancetoolforincludingCommunitySystemsStrengtheningin GlobalFundproposals;UNAIDS2009(neweditioninpreparation2010) http://data.unaids.org/pub/Manual/2009/20090218_jc1667_css_guidance_tool_en.pdf

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5. ASYSTEMATICAPPROACHFORDEVELOPINGCSSINTERVENTIONS INCLUDINGMONITORINGANDEVALUATION
Theobjectiveofthischapteristoprovideguidance to CSS implementers on the different steps to be undertakentobuildorstrengthenasystemforCSS interventions. CSS implementers will generally be larger organisations such as Principal Recipients, Governmental departments or large NGOs that work with community organisations and actors. A functional system for CSS interventions addresses identified needs and demonstrates progress towardsstrengtheningcommunitysystems.Table3 provides a summary of the key steps to be undertaken by CSS implementers. These steps are explainedingreaterdetailbelow. Step1:Thefirststepistoidentifywherecommunity system strengthening interventions are required. This decision should be based on the priorities identified in respective national disease strategic plansand/orinthehealthsector.Dependingonthe countrycontextthefocusofCSSinterventionscould beforexampletostrengthen: Allcommunitybasedorganisationsforthe deliveryofservicesinaspecificgeographic areasuchasadistrictoraprovince; Allcommunitybasedorganisationsworking withaspecificpopulationsubgroupsuch asvulnerablepopulations,orphansand vulnerablechildren,orpeoplelivingwitha specificdiseaseinacountry; The aim of CSS should not be to strengthen individual organisations but to strengthen the communitysystemasawhole.Forthisreasonwhen choosingtoworkonaspecificgeographicareaitis recommended to focus on all organisations in this area that are involved with service delivery for a particulardisease.Theseorganisationswilltogether formthedenominatorfortheCSSindicators.More informationabouthowtodefinethedenominatoris includedinchapter6.1oftheCSSFramework. Table3:summary ofthestepstobeundertakenby CSS implementers for the development of a system forCSSinterventions Step1: Definewherecommunitysystems strengtheninginterventionsatarerequired inordertosuccessfullyimplementthe healthsectorplans/specificdisease programs. Step2: Conductaneedsassessmenttodetermine thestrengthsandweaknessesofthe communitysysteminthetargetedarea(s). Step3: Basedonexpectedresults,defineclearand achievableobjectives. Step4: DeterminetheSDAswherestrengthening interventionsarerequired. Step5: ForeachoftheselectedSDAsagreeonthe mostappropriateCSSinterventions. Step6: SelectanumberofCSSindicatorsand modifyasneededtofitwiththespecific countrycontext. Step7: Determinebaselinesforeachofthe selectedindicators,setambitiousyet realistictargetsandfinalizethebudgetand workplanfortheCSSinterventions. Step8: EnsurethatM&EforCSSisintegratedinto thenationalreportingsystem. Step9: Reachanagreementonrolesand responsibilitiesofthevariousstakeholders involved. Step10: evelopharmonizeddatacollection D methodsandformats.

Step 2: The CSS implementing organisation should Step11: eachagreementonarrangementsfor R conduct a needs assessment to determine the regularsupervisionandfeedback. strengths and weaknesses of targeted community Step12: etanagendaforjointprogramreviewand S systems. It is of key importance that all relevant evaluation. stakeholders are consulted during the needs assessmentandthattheassessmentisconductedinafullyparticipatorymanner.Relevantstakeholdersmay

33

include representatives of community based organisations, representatives of key affected populations, nationalorprovinciallevelprogrammemanagers,localgovernmentofficials,M&Eexperts,representativesof the CCM, technical partners, disease experts, and others. Before a proposal can be developed, key stakeholders and partners must fully understand the service delivery environment by mapping who is providingwhichservices,towhomandwhere,andwhoisnotbeingreached.Agoodneedsassessmentwould systematically analyze the status of community systems for all 6 core components. The outcome of the assessment should clarify the current status of community systems and would clarify what needs to be strengthened. A needs assessment could involve the dissemination and analysis of printed or electronically administered questionnaires, community consultations and indepth mapping of partnerships and interventions.Duringtheplanningphasepleasekeepinmindthattheneedsassessmentshould: 1. 2. 3. 4. befeasibletoimplement identifythecurrentstatusofcommunitysystems(thebaselines) identifythekeyplayersinvolvedintheCSSinterventions(thestakeholders) informwhatshouldbeachieved

To support this process an assessment tool could be used.41 The Global Fund is currently developing such a toolincooperationwithpartners;thisshouldbeavailableinthesecondhalfof2010. Step3:Buildingontheneedsassessment,clearand achievable objectives should be identified. Table 2 provides an overview of how a strengthened community system could look like. This table could be used for the development of the objectives. Please keep in mind that CSS objectives should be consistent with the objectives of the national diseasecontrolorhealthsectorstrategicplan.Good objectivesaredefinedinaSMARTway,seetable4. Table4: SMARTobjectives SMARTobjectivesare: Specific(concrete,detailed,welldefined); Measureable(intermsofnumbers,quantity, comparison); Achievable(feasible,actionable); Realistic(consideringresources); TimeBound(definedtimeline).

Step4:Buildingontheobjectivesandtheoutcomeoftheneedsassessment,determinethelistofSDAsfor whichsystemstrengtheningmeasuresarerequired.Itisimportanttounderstandthatthe6corecomponents and the 10 SDAs are all equally essential for building strong community systems. In countries were one or moreofthecorecomponentsorSDAsarealreadywellfunctioning,theCSSimplementingorganisationshould focusonthoseareaswherestrengtheningismostrequired.CorecomponentsandSDAscanbestrengthened stepwise,e.g.inyear1thefocuscanbeonstrengtheningaparticularsetofSDAswhileinyear2thefocuswill beonadifferentsetofSDAs. Step5:Inconsultationwithcommunitystakeholdersandtechnicalpartnersdiscussthemostappropriateand effective interventions for each of the selected SDAs. CSS interventions should aim at ensuring that quality services are available and used by the community, which results in improved health outcomes at the community level. Ensure that the selected interventions are based on evidence and match with the needs identifiedbythecommunity.AnumberofexampleactivitiesareincludingforeachoftheSDAsinchapter3of thisdocument. Step6:Whenadecisionhasbeenmaderegardingthetypesofinterventions,thenitisnecessarytoworkon theindicatorstomeasureprogressinCSSovertime.Chapter6.2providesanoverviewoftherecommended
MoreinformationonhowtoconductaCSSneedsassessmentcanbefoundin:Supportingcommunitybasedresponses toAIDS:AguidancetoolforincludingCommunitySystemsStrengtheninginGlobalFundproposals;UNAIDS,January2009; http://data.unaids.org/pub/Manual/2009/20090218_jc1667_css_guidance_tool_en.pdf (updated version in preparation 2010)
41

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CSSindicatorsforuse.Chapter6.3containsdetaileddefinitionsforeachoftheindicators.Itisimportantto understandthatnotallindicatorslistedinthisdocumentarerelevantforeachCSSprogramme. A great variety of organisations are active at community level and there are also regional and national variationstotakeintoaccount.Atailoredpackageofwellselectedindicatorsshouldtherforebeselectedtofit withthespecificcountryandorganisationalcontext.Forthisreasonmanyoftheindicatorshavebeendefined ratherbroadlytoallowforflexibility. Forexample,someoftheindicatorsmakereferencetominimumcapacitytodeliverservices(indicator7.1). For this indicator, specific standards for minimum capacity will have to be defined that fit with the country context. Also the reporting frequency should be adjusted for each of the indicators to match with existing reporting cycles. In addition, the indicator definitions should be adjusted if key affected populations are targeted in concentrated epidemics. Some indicators might be more relevant for measuring CSS for larger moreadvancedCBOswhileothersaremorerelevantforsmallerCBOs. ItisrecommendedtoselectalimitednumberofindicatorsfortheCSSinterventions.ACSSprogrammecould contain around 10 to 15 indicators or if included in a disease component around 4 to 6 indicators. Furthermore,itisimportanttonotethatCSSindicatorscannotbecompletelyseparatedfromHSSindicators. SomeindicatorswillcoverbothCSSandHSS,suchasindicator6.4Communitybasedorganisations/facilities thatmaintainacceptablestorageconditionsandhandlingprocedures.TheindicatorscouldbeusedforGlobal Fundsupportedprogrammesbutalsoforotherprogrammes. Inconsultationwiththeidentifiedstakeholders,reachagreementontheuseofalimitednumberofsimpleto use, clearly defined and harmonized CSS indicators. Ensure consistency between the gap analysis of the community systems and the selected SDAs and indicators. Make sure that collected data is useful for programmemanagementatthenationallevelandensurethatqualitydatacanbeproducedforeachofthe selectedCSSindicators.Dataqualityneedstobeembeddedinallpartsofthedatamanagementsystemand shouldbestrengthenedthrough: PublicationofandadherencetoM&Eguidelines; Training&retrainingofstaffinM&E; Provisionoffrequentwrittenfeedbackandsupervision; Standardizationofdatabases; Useofexistingdataqualityassurancetoolsandadherencetodataqualityassuranceprotocols.

Step7:Thenextstepwillbetodevelopthebudgetandworkplan,todefinebaselinesandtosettargets.The needs assessment conducted in step 3 should give an idea with regards to the baselines for each of the selectedindicators.NowdefinethescaleinwhichtheCSSinterventionsshouldbeimplementedtoreachthe set objectives. Take into account limitations such as availability of human and material resources, environmental obstacles such as geography and terrain as well as political and physical infrastructure. DeterminetheresourcescurrentlyavailableforCSSinterventionsandidentifywhatandhowmanyadditional resources will be required. Building on this analysis set ambitious yet realistic targets for all selected CSS indicators.42Ensurethattargetsareachievableandthatallstakeholdersinvolvedhaveaclearunderstanding oftheirrespectiveroles,responsibilitiesandcontributions.NowfinalizetheworkplanandbudgetfortheCSS interventions. Remember that the budget should provide detailed assumptions of estimated costs for all planned activities. The work plan should identify a clear timeline and responsible actors for the implementationofeachoftheplannedactivities.
42

Fortargetsettingreferforexampleto:TechnicalGuideforcountriestosettargetsforuniversalaccesstoHIVprevention, treatmentandcareforinjectingdrugusers;WHO,UNODC,UNAIDS2009: http://www.who.int/hiv/pub/idu/targetsetting/en/

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Step 8: Information related to CSS such as leadership, advocacy, governance and accountability is often not capturedbyhealthinformationmanagementsystems.Otherissuessuchasresourcemobilization,partnership and staff performance at the community level are only captured to a certain extent but require further integration.Strongleadershipandjointplanningwithcommunitystakeholdersarekeytocreatingaconducive environmentfortheintegrationofM&EforCSSintothenationalreportingsystem.WhensettinguptheM&E systemforCSSinterventions,itisimportanttoensurethatthereportingflowfollowsexistingreportinglines andestablishedstructures.AlsoensurethatthereisnoparallelsystemforreportingonCSSwithinorbetween disease components through close coordination between community based organisations, other community actorsandlocalgovernmentauthorities. Step9:ItisveryimportantthatallstakeholdersinvolvedintheCSSprogrammehaveaclearidearegarding theirrolesandresponsibilities.Agoodwayofensuringthateverybodysharesacommonunderstandingisby developing memoranda of understanding between community based organisations involved and the CSS implementer. Step10:Appropriatereportingformsanddatacollectiontoolswillneedtobedevelopedinconsultationwith thecommunitybasedorganisationsandactors.Toolsandformsshouldbeeasytouseandshouldonlycapture informationthatisusefulforprogrammemanagementandinformeddecisionmaking.Itisofkeyimportance that the same tools and forms are used by all stakeholders involved in the CSS programme to facilitate integration of data into the national reporting system. Not all information collected at the community level needstobereportedtothenationallevel.CommunitystakeholdersandCSSimplementersshoulddiscussand agreewhatneedstobereportedon. Step11:Reachagreementonarrangementsforregularsupervisionandfeedback.Thepurposeofsupervision and feedback is to improve the quality of programmes and to create an environment to enable staff to performtotheirmaximumpotential.Supervisionshouldbesupportiveandisnotameansforcontrollingthe performanceofanindividualoranorganisation.Supervisionnormallyincludesskillsdevelopment,reviewof recordsandreports,fieldvisits,qualityassuranceandpersonalaswellasprofessionaldevelopmentthrough onthejobtrainings.Itcaninvolveindividualsessionsorgroupsessions.Supervisionisanopportunityfortwo wayfeedbackandensuringimprovedunderstandingofthetasksandissuesinvolvedindeliveringhighquality services. Step12: hefinalstepwillbetosetanagendaforjointprogrammereviewandevaluation.Jointprogramme T reviews and evaluations shed light on the outcome and impact of programmes and contribute to building mutual understanding of longterm strategies, goals and objectives. They aim to answer the following questions: Whatresultshaveweachievedagainstthepredefinedtimeboundtargets? Arewedoingtherightthings? Arewedoingthemintherightway? Arewedoingthematalargeenoughscale?

Itisimportantthatcommunitysystemstrengtheningisintegratedintheannualdisease/healthsectorreview tostrengthenthelinkbetweenthecommunityandthenationalprogramme.Communitybasedorganisations andactorsshouldbesystematicallyinvolvedinjointevaluations,operationalresearchandreviews.43

43

UsefulresourcesonreviewandevaluationcanbefoundatthewebsiteGlobalHIVM&Einformation: http://www.globalhivmeinfo.org/DigitalLibrary/Pages/12%20Components%20HIV%20Evaluation%20Research%20and%20 Learning%20Resources.aspx

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6. INDICATORSFORCSS
6.1DEVELOPMENTOFCSSINDICATORS
This chapter contains 27 recommended indicators for CSS. These indicators have been developed in consultation with a large number of stakeholders representing key affected populations, community based organisations,governmentsandvariousbilateralandmultilateralorganisations.Table5providesanoverview ofthekeymilestonesintheCSSindicatordevelopmentprocess.

Table5:CSSindicatordevelopmentprocess: August2008:TheGlobalFundcommissionedareviewexerciseinPretoriawherealistof13CSSindicators wasdeveloped; January 2009: UNAIDS developed a guidance tool for including Community Systems Strengthening in GlobalFundproposalsandincludedanumberofrecommendedindicatorsforCSS; NovemberDecember2009:AmultipartnertechnicalworkinggrouponCSScommissioned9casestudies indifferentcountriesoncommunitysystemsstrengtheningandcommunitylevelmonitoring&evaluation. DuringthefieldexercisesalargenumberofCSSindicatorswerecollected; February 2010: During a harmonization workshop in Geneva, existing CSS indicators were reviewed by M&EexpertsrepresentingUNAIDS,WHO,USAID,OGAC,MeasureEvaluation,theInternationalHIV/AIDS Alliance,7SistersandTheGlobalFundandanewlistwasdevelopedalignedwiththecorecomponents andSDAsoftheCSSFramework; March2010:AninternalreviewandfurtherdefinitionoftheCSSindicatorswasconductedbytheGlobal Fund.CommentsfromthetechnicalworkinggrouponCSSandotherswereintegratedintothisprocess; CSSindicatorswerereviewedandupdatedduringa2daycivilsocietyconsultationmeetinginBrighton; April 2010: Several rounds of ebased reviews were conducted with various stakeholders including representativesofkeyaffectedpopulationsandcommunityactorsandorganisations. AnumberofselectioncriteriaincludingtheUNAIDSMERGindicatorstandards44haveguidedtheCSSindicator developmentprocess.Table6providesanoverviewofthesecriteria. The list of indicators contained in this document is work in progress. CSS implementers are encouraged to make use of them but it is essential to understand that there are a number of limitations to take into consideration: Firstly, it is important to understand that the main objective of CSS interventions is to contribute to better servicedelivery,resultinginimprovedhealthoutcomesatthecommunitylevel.Forthisreasonitisimportant that both CSS indicators and community level service delivery indicators are used simultaneously. Table 7 explainsthedifferencebetweenthesetwotypesofindicators.ThisdocumentonlycontainsrecommendedCSS
44

UNAIDSMERGIndicatorStandards:OperationalGuidelinesforSelectingIndicatorsfortheHIVResponseindicator, availableat: http://www.globalhivmeinfo.org/AgencySites/MERG%20Resources/MERG%20Indicator%20Standards_Operational%20Gui delines.pdf

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indicatorsbutdoesnotprovideindicatorstomonitorservicedeliveryatthecommunitylevel.Forcommunity levelservicedeliveryindicators,otherresourcesshouldbereferredtosuchasTheGlobalFundMonitoringand EvaluationToolkit.45 Table6:CriteriaforthedevelopmentofCSSindicators UNAIDSMERGindicatorstandards: Theindicatorisneededanduseful Theindicatorhastechnicalmerit Theindicatorisfullydefined Itisfeasibletocollectandanalyzedataforthisindicator Theindicatorhasbeenfieldtestedorusedinpractice

AdditionalcriteriaappliedfortheselectionofCSSindicators: Secondly,manyoftheindicatorsarenewlydevelopedandnotallhavebeenfieldtestedorusedinpractice. ForthisreasontheCSSindicatorswillbepilottestedin2010andfurtherfinetunedwherenecessary. Thirdly, the indicators focus mainly on CSS inputs, processes and outputs. The outcomes and impacts of CSS interventions should be measured by disease specific indicators focusing for example on prevalence or mortalityrate.Thisalsomeansthatthelistof CSS indicators focuses more on monitoring thanonevaluation.However,evaluationisan important component of M&E and actors involvedwithCSSareencouragedtoalsothink aboutsettingupanevaluationsystemthatcan be implemented when the monitoring system isinplaceandfunctioningwell. Table7:Communitysystemstrengtheningindicatorsand communitylevelservicedeliveryindicators An effective diseasespecific programme collects both CSS indicators and community level service delivery indicators. CSS indicators measure the strengths and weaknesses of community systems. Community level service delivery indicators measure the actual services deliveredatthecommunitylevel. An example of a CSS indicator is: Number and percentageofcommunitybasedorganisationsthathave corefundingsecuredforatleast2years. The indicator allows to measure quantitative improvements over time, e.g. indicators that can onlybeansweredwithyesornowerenotconsidered; Theindicatorissimpleandeasytousebyallactorsofthereportingsystem.

Finally, for some of the SDAs only a limited An example of a community level service delivery indicator is: Number of adults and children living with numberofindicatorsareproposed.(e.g.SDA1 HIV who received care and support services outside currentlyonlycontains1indicator).Thereason for this small number of indicators is that facilitiesduringthereportingperiod. issues such as advocacy or enabling environmentsaredifficulttomeaningfullycaptureinquantitativevalues.ForthisreasontheGlobalFundand partners are planning to develop an index for CSS similar to the UNGASS National Composite Policy Index

45 Monitoring and Evaluation Toolkit HIV, Tuberculosis and Malaria and Health Systems Strengthening, 3rd edition; The GlobalFund2009;http://www.theglobalfund.org/documents/me/M_E_Toolkit.pdf

38 (NCPI)46.Thisindexwillincludeanumberofyes/noquestionscoveringareaswherenogoodindicatorscould beformulated. Examplesofthesetypesofquestionscouldbe: Havebarrierstoequitableaccesstohealthservicesbeenidentified? Arelegalarrangementssuchasantidiscriminationlawsinplaceforthedevelopmentofanenabling environment? Arepubliccampaignsorganizedbythecommunityresultinginpolicychange?

The index will produce a score reflecting the current situation of targeted community systems. CSS implementing organisations will be encouraged to use this tool to assess the status of their community systems once every two or three years. The results of these assessments will provide a measure of CSS improvementovertime. BeforedevelopingorusingtheCSSindicatorspleasemakesurethatyouhavereadthefollowing: Community based organisations: Many of the indicators focus on community based organisations. While acknowledgingtheimportantroleofcommunitybasedorganisationsindeliveringservicestothecommunity, it is also important to acknowledge that other actors contribute to this process. Examples of other organisations involved in service delivery to the community are: private sector organisations, non governmental organisations or local government authorities. CSS interventions could focus on community based organisations but also on these other types of organisations. When working with other types of organisations,itisimportanttoadjusttheindicatorstofitwiththesetargetedorganisationsaswellasreflect thelinkbetweentheseorganisationsandthecommunity. Definition of the denominator: Many of the indicators have total number of targeted community based organisationsorallcommunitybasedorganisationsinatargetedareaastheirdenominator.Itisessentialto adjustthisdenominatortothespecificCSSprogramme.Thedenominatorshouldbedeterminedinstep1of the development of a system for CSS. Furthermore, it is important to strengthen community systems as a wholeandnottofocusonlyonalimitednumberofcommunityactorsororganisations.Examplesofadjusted denominatorscouldbe: Allcommunitybasedorganisationswithlessthan100staffmembersorvolunteersindistrictxthat areinvolvedwithprevention,careortreatmentservicesforHIV/AIDS. AllorganisationsinprovincexsupportingTBpatientsadherencetotreatmentincludingCBOs,NGOs, FBOsandprivatesectororganisations. Allcommunitybasedorganisationsincountryxthatworkwithorphansandvulnerablechildren.

Staff/volunteers:Alargeproportionofcommunityservicesaredeliveredbyvolunteers.Volunteerscontribute considerable added value to improving health outcomes at the community level and are for that reason systematicallyincorporatedinallindicatorsfocusingonstaff.Communityvolunteersmayincludearangeof includearangeofnonhealthworkers,includingofficeworkers,drivers,activityorganisersetc.Theymayalso include a variety of health workers such as peer educators, community health outreach workers, DOTS coordinators, village health workers, malaria village workers, homebased care providers, outreach workers, health educators, health promoters and other volunteers in accordance with the individual countrys definition.
46

MoreinformationontheUNGASSNationalCompositePolicyIndexisintheUNGASSGuidelinesfor2010reporting: http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090331_UNGASS2010.asp

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Training: Many of the indicators focus on training. Training offered to a staff member or volunteer aims at updatingoraddingnewknowledgeandskills.Trainingnormallyreferstoaninteractiveprocesswhichlastsfor multipledays.E.g.participatinginaonedayworkshopisnotconsideredasreceivingtraining.Whentraining indicatorsareusedpleaseensurethatspecifictrainingmodalitiesaredefinedbeforehand.

6.2OVERVIEWOFRECOMMENDEDCSSINDICATORS
Corecomponent1:Enablingenvironmentsandadvocacy SDAs SDA1:Monitoringand documentationof communityand government interventions Indicators Numberandpercentageofcommunitybased organisationsthathavebeeninvolvedinjoint nationalprogrammereviewsorevaluationsinthe last12months(1.1) Source ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

SDA2:Advocacy, Communicationand Socialmobilisation

Numberandpercentageofcommunitybased organisationsthatimplementedacosted communicationandadvocacyplaninthelast12 months(2.1) Numberandpercentageofcommunitybased organisationswithastaffmemberorvolunteer responsibleforadvocacy(2.2)

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

Corecomponent2:Communitynetworks,linkages,partnershipsandcoordination Numberandpercentageofcommunitybased organisationsthatarerepresentedinnationalor provincialleveltechnicalandpolicybodiesof diseaseprogrammes(3.1) SDA3:Building communitylinkages, collaborationand coordination Numberandpercentageofcommunitybased organisationsthatdeliverservicesforprevention, careortreatmentandthathaveafunctionalreferral andfeedbacksysteminplace(3.2) Numberandpercentageofcommunitybased organisationsthatheldatleastonedocumented feedbackmeetingwiththecommunitytheyservein thelast6months(3.3) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

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Corecomponent3:Resourcesandcapacitybuilding Number and percentage of community health AdaptedM&EToolkit workers and volunteers currently working with HSSHR2 community based organisations who received training or retraining in HIV, TB or malaria service delivery according to national guidelines (where suchguidelinesexist)inthelast12months(4.1)

SDA4:Humanresources: skillsbuildingforservice delivery,advocacyand leadership

Number and percentage of staff members and AdaptedM&EToolkit volunteers currently working for community based HSSHR3 organisationsthathaveworkedfortheorganisation formorethan1year(4.2)

Number and percentage of community based AdaptedM&EToolkit organisations that received supervision and HSSHR7 constructive feedback in accordance with national guidelines (where such guidelines exist) in the last 3/6months(4.3)

Number and percentage of volunteers working for AdaptedM&EToolkit community based organisations that are provided HSSHR9 withastipend/allowance(4.4)

SDA5:Financial resources

Numberandpercentageofcommunitybased organisationsthatsubmittimely,completeand accuratefinancialreportstothenationally designatedentityaccordingtonationally recommendedstandardsandguidelines(where suchguidelinesexist)(5.1)

AdaptedM&EToolkit HSSHI7

Number and percentage of community based ConsultativeCSS organisations thathavecorefunding secured forat indicatordevelopment least2years(5.2) process(FebruaryApril 2010)

SDA6:Materialresources infrastructureand essentialcommodities (includingmedicaland otherproducts& technologies)

Numberandpercentageofcommunitybased organisationsreportingnostockoutofessential commoditiesduringthereportingperiod(6.1) Numberandpercentageofcommunitybased organisationsthatkeepaccuratedataforinventory management(6.2)

AdaptedM&EToolkit TB1.3.1

AdaptedM&EToolkit HSSHP2

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Numberandpercentageofcommunitybased organisationswithstafforvolunteerstrainedorre trainedinstockmanagementinthelast12months (6.3) Numberandpercentageofcommunitybased organisationsthatmaintainadequatestorage conditionsandhandlingproceduresforessential commodities(6.4) Corecomponent4:Communityactivitiesandservicedelivery Numberandpercentageofcommunitybased organisationswiththeminimumcapacitytodeliver servicesaccordingtonationalguidelines(wheresuch guidelinesexist)(7.1) Numberandpercentageofpeoplethathaveaccess tocommunitybasedHIV,TBormalariaservicesina definedarea(7.2)

AdaptedM&EToolkit HSSHP3

AdaptedM&EToolkit HSSHP4

SDA7:Community basedactivitiesand servicesdelivery,use andquality

AdaptedM&EToolkit HSSSD4

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

Corecomponent5:leadershipandorganisationalstrengthening Numberandpercentageofcommunitybased organisationswithstafforvolunteerswhoreceived trainingorretraininginmanagement,leadershipor accountabilityinthelast12months(8.1) Number and percentage of staff members and volunteers of community based organisations with written terms of reference and defined job duties (8.2) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

SDA8:Management, accountabilityand leadership

Numberandpercentageofcommunitybased organisationsthatreceivedtechnicalsupportfor institutionalstrengtheninginthelast12months(8.3)

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

42

Corecomponent6:Monitoring&EvaluationandPlanning Numberandpercentageofcommunitybased organisationswithastaffmemberorvolunteer responsibleformonitoringandevaluation(9.1) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010) ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

Numberandpercentageofcommunitybased organisationsthatareimplementingacostedannual workplanwhichincludesmonitoringandevaluation activities(9.2)

SDA9:Monitoring& evaluation,evidence building

Numberandpercentageofcommunitybased organisationswithatleastonestaffmemberor volunteerwhoreceivedtrainingorretrainingin planningorM&Eaccordingtonationally recommendedguidelines(wheresuchguidelines exist)inthelast12months(9.3) Numberandpercentageofcommunitybased organisationsusingstandarddatacollectiontoolsand reportingformatswhichenabletoreporttothe nationalreportingsystem(9.4) Numberandpercentageofcommunitybased organisationsconductingreviewsoftheirown programmeperformanceinthelast3/6months(9.5)

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

AdaptedM&EToolkit HSSHI5

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

SDA10:Strategic planning

Numberandpercentageofcommunitybased organisationswithadevelopedstrategicplan covering3to5years(10.1)

ConsultativeCSS indicatordevelopment process(FebruaryApril 2010)

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6.3DETAILEDCSSINDICATORDEFINITIONS
BeforeusingtheCSSindicatorspleasemakesurethatyouhavereadthefollowing: Please note that most of the indicators refer to community based organisations. However it is important to understand that other organisations such as private sector organisations, NGOs, FBOs, networks of people livingwithHIV,pharmaciesorlocalgovernmentsarealsoinvolvedinservicedeliverytothecommunity.Before usingtheCSSindicatorspleasemakesurethatthedefinitionsareadjustedtoincludealltypesoforganisations thatareincludedinaspecificCSSprogramme. Regarding the definition of the denominator, many of the indicators have total number of targeted community based organisations or all community based organisations in a targeted area as their denominator.ItisessentialtoadjustthisdenominatorsothatitisalignedwiththespecificCSSprogrammefor which it will be used. Section 6.1 of this chapter (above) provides more details on how to define the denominator.

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(1.1) Numberandpercentageofcommunitybasedorganisationsthathavebeeninvolvedinjointnational programmereviewsorevaluationsinthelast12months

Rationale Nationaldiseaseprogrammesundertakeprogrammereviewsandevaluationsforacomprehensiveappraisalof the programme. This enables them to formulate conclusions and recommendations for improving the programme implementation. There are multiple objectives, including review of the structure, policies and proceduresofthenationalprogramme,deliveryofservices,clientsatisfaction,variousresources,partnerships, monitoringandevaluationprocedures,socialmobilization,etc.Usually,appropriatenationalandinternational technical partners and stakeholders are involved in programme reviews and evaluations, which include a review of documents, field visits, interviews with staff and clients, review of facilities, etc. Joint national programmereviewsandevaluationsareusuallyperformedaccordingtoanagreedprotocol. Joint national programme reviews and evaluations help to identify gaps, create opportunities for finding synergies between community and health system responses to HIV, TB and malaria and are a platform for sharing and documentation of information and experiences. Joint national programme reviews and evaluations contribute to building mutual understanding of longterm strategies, goals and objectives to effectivelystopandreverseepidemicdiseases. Definitionoftheindicator This indicator measures the participation of community based organisations in joint national programme reviews and evaluations. All organisations that contribute to reaching the objectives of the national programme should normally be involved in joint national programme reviews or evaluations. Joint national programmereviewsandevaluationscanbeconductednationwidebutalsoinaspecificdistrictorprovince. Numerator: Total number of community based organisations targeted for CSS that report that theyhavebeeninvolvedinatleastonejointprogrammerevieworevaluationatthe nationalorprovinciallevelduringthelast12months. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement Community based organisations are requested to report whether or not they have been involved in a joint programmerevieworevaluationduringthelast12months. Datasources: Frequency: Administrativerecords;evaluationreports Annually

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(2.1) Number and percentage of community based organisations that implemented a costed communicationandadvocacyplaninthelast12months
Rationale Communication and advocacy are integral parts of the work of community based organisations. A communication and advocacy plan should be developed and implemented to fight against stigma and discrimination,improveaccesstoqualityhealthservicesandeffectivelymobilizecommunityresponsestoHIV, TBandmalaria. Definitionoftheindicator This indicator measures in the first place the existence of a costed plan that includes communication and advocacyactivities.Theseactivitiescouldbeintegratedinthegeneralworkplan,couldbepartofaseparate communication and advocacy plan or could be integrated into another type of costed plan. Secondly, this indicator measures whether communication and advocacy activities included in the costed plan are actually beingimplemented. Acostedplanprovidesestimatedcostsforallactivitiesincludedintheplan. Numerator: Total number of community based organisations targeted for CSS which demonstrate that they have implemented communication and advocacy activities includedinacostedplanduringthelast12months. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement Organisations targeted for CSS are requested to submit a costed plan which includes communication and advocacyactivitiesalongwithrecordsoftheimplementationoftheseactivitiesaccordingtotheplaninthe last12monthsatthetimeofreporting.Forthecalculationofthenumerator,communitybasedorganisations thatimplementedatleastonecommunicationandadvocacyactivityincludedintheircostedplanshouldbe counted. Datasources: Costedplanscontainingcommunicationandadvocacyactivities,regularprogramme reporting Annually

Frequency:

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(2.2) Number and percentage of community based organisations with a staff member or volunteer responsibleforadvocacy
Rationale Conductingsuccessfuladvocacyactivitiesrequiresstrongevidenceanddocumentation,butalsohighlyskilled staffwiththeabilitytoidentifyeffectivestrategies.Advocacyrequiresadegreeofdedicationandstafftime allocationandshouldnotbeaddedtotheexistingworkloadofprogrammestafforvolunteers. Definitionoftheindicator Thisindicatormeasuresthenumberandpercentageofcommunitybasedorganisationswithastaffmemberor volunteerresponsibleforplanningandimplementationofadvocacyactivities.Thisstaffmemberorvolunteer can also be involved with other activities of the organisations but is responsible for all advocacy activities. Advocacy activities may include public campaigns through advertisements, public events, internet, or other forms of media. It can also include policy dialogue with government officials at various levels, community mobilization to address specific issues or concerns and other activities aimed at improving policies or social and political environments for the improvement of quality and accessto HIV, TBand malariarelated health services. Numerator: Total number of community based organisations targeted for CSS that are conducting advocacy activities, with a staff member or volunteer responsible for planningandimplementationofadvocacyactivities. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement OrganisationstargetedforCSSarerequestedtosubmitthenameofthestaffmemberorvolunteerresponsible fortheadvocacyactivitieswithintheorganisation.Writtentermsofreferencedefiningthejobdutiesofstaff membersorvolunteersshouldalsobeprovided. Datasources: Frequency: Administrativerecords,termsofreference Annually

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(3.1) Number and percentage of community based organisations that are represented in national or provincialleveltechnicalandpolicybodiesofdiseaseprogrammes
Rationale This indicator intends to measure participation by community based organisations in national or provincial leveldecisionmakingontechnicalandpolicyissues. Definitionoftheindicator This indicator includes representation in national or provincial level technical and policy bodies either by a representativeofthecommunitybasedorganisationorbyarepresentativeofanetwork/associationofwhich thecommunitybasedorganisationisamember.Communityrepresentationthereforemeansthatatleast one staff member or volunteer of the targeted organisation or one staff member or volunteer of a network/association representing the targeted organisation, is a member of a technical or policy body and participatedinatleastonemeetingduringthelast12monthsasdemonstratedbyacopyoftheattendance listofthemeetingatthetimeofreporting. Nationalleveltechnicalandpolicybodiesmayincludethoserelatedtostrategicplanning,policyandguideline development,oversight,operationalresearch,involvementoftheprivatesectorandothers.Thesebodiescan bedirectlyrelatedtoHIV,TBormalariabutalsotobroaderhealthissues. Numerator: Total number of community based organisations which report that they were represented in at least one meeting of a national or provincial level technical or policy body of the national disease programmes during the last 12 months at the timeofreporting. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Limitation Thisindicatormeasurestherepresentationofcommunitybasedorganisationsbutwillnotnecessarilymeasure theimpactoftheirparticipation. Measurement Targeted community based organisations are requested to report whether or not they were directly or indirectlyrepresentedinatleastonemeetingofanationalorprovincialleveltechnicalorpolicybodyofthe national disease programmes during the last 12 months at the time of reporting. Attendance should be demonstratedbysubmittingthelistofparticipantofthemeeting.Communitybasedorganisationsthathavea representativeinatechnicalorpolicybodybutwhodidnotattendanymeetinginthelastreportingperiod shouldnotbetakenintoconsiderationforthecalculationofthenumerator. Datasources: Frequency: Administrativerecords,participantslists Annually

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(3.2) Numberandpercentageofcommunitybasedorganisationsthatdeliverservicesforprevention,care ortreatmentandthathaveafunctionalreferralandfeedbacksysteminplace

Rationale Thisindicatorwillmeasurewhethercommunitybasedorganisationsthatdeliverservicesforprevention,care ortreatmentdosoincollaborationwithothercommunitybasedorganisationsand/orwithpublichealthcare institutionsthroughimplementationofafunctionalreferralandfeedbacksystem. Definitionoftheindicator Delivering services in collaboration with other community organisations and public institutions refers to servicesprovidedjointlybycommunitybasedorganisationsandthepublichealthcaresystem.Forexample, outreachvoluntarytestingandcounselingservicecouldbedeliveredjointly,wherelaboratorystafffromthe public health institution perform rapid HIV tests and the community workers provide pre and post test counseling. In a functional referral and feedback system, community based organisations refer clients for servicestoothercommunityorganisationsortopublicinstitutionsandreceivefeedbackonservicesprovided totheclientsreferredbythemandviceversa. Numerator: Community based organisations that deliver services for prevention care or treatmentandthathaveafunctionalreferralandfeedbacksysteminplace. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Limitation This indicator does not measure the extent to which the services are provided by community based organisations and the public institutions. In some cases community based organisations will only be responsibleforreferringclientstoanothercommunitybasedorganisationorapublicinstitution;inothercases theywillalsobeinvolvedindeliveringtheactualservicessuchascounseling. Measurement Communitybasedorganisationsarerequestedtosubmitevidenceoftheservicestheydeliverincollaboration with other community organisations or public institutions. They should also provide evidence on the functionalityoftheirreferralandfeedbacksystem.Evidencecanbeprovidedintheformofareportand/or other supporting documentation. The data received should be crosschecked with the records from other communityorganisationsorpublicinstitutions. Datasources: Annualreportsandsupportingdocumentationfromcommunitybased organisations;referralslips;patientrecords. Annually

Frequency:

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(3.3) Number and percentage of community based organisations that held at least one documented feedbackmeetingwiththecommunitytheyserveinthelast6months
Rationale Thisindicatorintendstomeasurecommunitylinkages.Meetingsareagoodmethodof2waycommunication between community based organisations and the community itself and provide the community with an opportunitytoparticipateandestablishstronglinkages. Definitionoftheindicator Thecommunityreferstoallindividualsthatcommunityactorsandorganisationsaimtoserve/support.This couldbespecificgroupssuchaspeoplelivingwithHIV,TBpatients,motherswithchildrenunder5yearsofage oraspecificpopulationsubgroupinadefinedgeographicoradministrativearea. Numerator: Totalnumberofcommunitybasedorganisationsthatheldatleastonedocumented feedbackmeetingwiththecommunitytheyserveinthelast6months. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Limitation Ifparticipantsarenotselectedwithcare,appropriatecommunitylinkageswouldnotbeestablisheddespite holdingdocumentedfeedbackmeetings. Measurement Targeted organisations are requested to report on the total number of feedback meetings held with the communitytheyserveinthelast6monthsatthetimeofreporting.Theyshouldalsosubmitwrittenminutes of meetings. These documents should be brief and should contain a participants list, the main issues of discussionandfollowupactions. Datasources: Frequency: Meetingminutes Every6months

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(4.1) Number and percentage of community health workers and volunteers currently working with community based organisations who received training or retraining in HIV, TB or malaria service deliveryaccordingtonationalguidelines(wheresuchguidelinesexist)inthelast12months
Rationale Available data suggest a shortage of community health workers that are delivering services for HIV, TB and malaria at the community level. This shortage jeopardizes the achievement of the Millennium Development Goalsrelatedtohealth.Actionisneededtoincreasethenumbersofpeopletrained,recruitedandretainedas communityhealthworkers. Definitionoftheindicator Community health workers and volunteers refer to all people who are involved in the delivery of health services to the community. This includes peer educators, community health outreach workers, DOTS coordinators, village health workers, malaria village workers, homebased care providers, outreach workers, healtheducators,healthpromotersandothervolunteersinaccordancewithanindividualcountrysdefinition. Numerator: Total number of community health workers and volunteers that have received training or retraining in HIV, TB or malaria service delivery according to national guidelines(wheresuchguidelinesexist)inthelast12monthsandthatareworking foranorganisationtargetedforCSSatthetimeofreporting. Total number of community health workers and volunteers working for an organisationtargetedforCSS.

Denominator:

Limitation: Thisindicatordoesnotmeasurethequalityofthetraining,neithertheoutcomeofthetrainingintermsofthe competencies of individuals trained or their job performance, nor the placement or retention of the health workforceoftrainedindividuals. Measurement Targetedorganisationsarerequestedtosubmitappropriateadministrativerecordstodemonstratethenames ofstaffmembersandvolunteersthatreceivedtrainingorretraininginHIV,TBormalariaservicedelivery.The organisationsshouldalsoreportwhetherornotthetrainedorretrainedstaffandvolunteersarestillworking fortheorganisationatthetimeofreporting.Onlystaffmembersandvolunteersthatreceivedtrainingorre traininginthelast12monthsandthatarestillworkingforthecommunitybasedorganisationatthetimeof reportingshouldbetakenintoconsiderationforthecalculationofthenumerator. Datasources: Frequency: Appropriateadministrativerecords Every3/6months

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(4.2) Number and percentage of staff members and volunteers currently working for community based organisationsthathaveworkedfortheorganisationformorethan1year
Rationale The community health sector experiences many challenges in retaining health professionals. This indicator intendstomeasuretowhatextentcommunitybasedorganisationsretaintheirstaffmembersandvolunteers. Definitionoftheindicator This indicator takes into consideration all categories of staff and volunteers who are currently working for community based organisations. This includes health professionals as well as other types of staff and volunteers. Numerator: Total number of staff and volunteers who are currently working for community basedorganisationsthathavefinishedmorethan12months of service for the organisation. Totalnumberofstaffandvolunteerswhoarecurrentlyworkingforanorganisation targetedforCSS. Different professional categories such as community health workers, outreach workers,counselorsetc.

Denominator:

Disaggregation:

Measurement

Targeted community based organisations are requested to submit a copy of appropriate administrative recordsthatshouldcontaintheinformationofthetotalnumberofstaffandvolunteersworkingforthemas wellasthenumberofmonthsofservicethestaffandvolunteerscompletedfortheorganisation. Datasources: Frequency: Administrativerecords Annually

52

(4.3) Number and percentage of community based organisations that received supervision and constructivefeedbackinaccordancewithnationalguidelines(wheresuchguidelinesexist)inthelast 3/6months
Rationale Constructive supervision is key to improving programme performance. This indicator measures whether providers of HIV, TB and malaria services at the community level receive constructive feedback on their performanceandcapacitybuildingtoimprovethequalityofservicesdelivered. Definitionoftheindicator Thepurposeofsupervisionistoimprovethequalityofprogrammesandtocreateanenvironmenttoenable staff and volunteers to perform to their maximum potential. Supervision should be supportive and is not a meansforcontrollingtheperformanceofanindividualoranorganisation.Supervisionnormallyincludesskills development,reviewofrecordsandreports,fieldvisits,qualityassuranceandpersonalaswellasprofessional development,onthejobtrainingandmentorship.Itcaninvolveindividualsessionsorgroupsessions,review ofinventory,laboratoriesandstoragefacilitiesetc.Supervisionisalsoanopportunityfortwowayfeedback andensuringimprovedunderstandingofthetasksandissuesinvolvedindeliveringhighqualityservices. This indicator does not only focus on supervision of service delivery but also on supervision of overall programme implementation which includes supervision in areas such as finance, logistics and human resourcesetc. For the calculation of the numerator only external supervision (provided by someone from outside the organisation) is counted. Internal supervision (for example provided by the head of a community based organisationtocommunityhealthworkerswithintheorganisation)isnottakenintoconsideration. Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSwhichreportthat theyhavereceivedsupervisioninthelast3/6months. Totalnumberoftargetedcommunitybasedorganisationsorallcommunity basedorganisationsinatargetedarea.

Denominator: Measurement

Targetedcommunitybasedorganisationsarerequestedtoreportwhethertheyreceivedsupervisionfroman externalorganisationduringthelast3/6months. Datasources: Frequency: Administrativerecords,supervisionreports Every3/6months

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(4.4) Numberandpercentageofvolunteersworkingforcommunitybasedorganisationsthatareprovided withastipend/allowance

Rationale This indicator intends to measure the efforts undertakenbycommunity based organisations to increase the retentionofvolunteers. Definitionoftheindicator A stipend or allowance is a type of remuneration that is mainly meant to cover the costs incurred while providingservicesandisnotequivalenttoasalary. Volunteers may include a range of nonhealth workers, including office workers, drivers, activity organisers etc. They may also include a variety of health workers such as peer educators, community health outreach workers, DOTS coordinators, village health workers, malaria village workers, homebased care providers, outreachworkers,healtheducators,healthpromotersandothervolunteersinaccordancewiththeindividual countrysdefinition. Some community based organisations may attract skilled volunteers from national and international organisations or affiliates that pay them directly (and not through the host community based organisation). This category of staff should, therefore, be considered paid volunteers and should not be counted. The volunteers working directly and/or collaborating with the local government authorities or any other recognizedentityshouldbecounted. Numerator: Total number of volunteers working for targeted community based organisations thatreceivedastipend/allowanceforprovidingservicesduringthelast3/6months. Totalnumberofvolunteersworkingforcommunitybasedorganisationstargetedfor CSS.

Denominator:

Measurement

Organisations targeted for CSS are requested to report on the total number of volunteers who provided services for the organisation and should identify how many volunteers were provided with a stipend/allowanceinthelast3/6monthsatthetimeofreporting.Theorganisationsshouldreportonthetype ofstipend/allowanceprovided. Datasources: Frequency: Administrativerecords Every3/6months

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(5.1) Number and percentage of community based organisations that submit timely, complete and accuratefinancialreportstothenationallydesignatedentityaccordingtonationallyrecommended standardsandguidelines(wheresuchguidelinesexist)
Rationale Goodfinancialreportingpracticescontributetotheefficientuseofavailablefundsandeffectiveallocationof resources. Definitionoftheindicator Forfinancialreportingatleastthefollowingdocumentsshouldbesubmitted: Financialstatementsasdescribedinthenationalguidelines(wheresuchguidelinesexist) Auditreports

Analysesofbudgetsversusexpenditure Timelymeansthatreportshavebeenreceivedbeforeoronthedayofthereportingdeadline. Completemeansthatallrelevantdatahasbeenprovided. Accuratemeansthatthefiguresreflecttheactualfinancialstatusoftheorganisation. Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSsubmittingtimely, complete and accurate financial reports according to nationally recommended guidelines(wheresuchguidelinesexist). Totalnumberoftargetedcommunitybasedorganisationsorallcommunity basedorganisationsinatargetedarea.

Denominator: Measurement

This indicator is measured through a review of the financial reports that were received during the last reportingperiodfortimeliness,completenessandaccuracy. Datasources: Frequency: Financialreports Every3/6months

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(5.2) Number and percentage of community based organisations that have core funding secured for at least2years
Rationale Corefundingisprovidedtoorganisationstoenablethemtodeliveronstrategicobjectivesandtoachieveset goals.Thistypeoffundingallowsorganisationstohavetheappropriatesupportandpaidstaffaccordingtoan organogram structured around the different streams of work, as well as having adequate office supplies, systemsandhardwareinplace.Corefundingenablesorganisationstogrowanddevelopandtoberesponsive tochange. Definitionoftheindicator Core funding refers to financial support that covers basic core organisational and administrative costs in addition to programmespecific requirements. Core funding provides stability, allowing organisations to operate their own chosen programmes. Community based organisations receiving core funding retain a significantdegreeofindependenceinselectingandimplementingprogrammeandorganisationalobjectives. Corefundingisnormallyoflongerdurationthanprojectfundingandisconsideredamorepredictableformof funding. Corefundingisdifferentfromprojectfundingwhichoftenfocusesexclusivelyonprojectcosts.Projectfunding typically allows organisations to include aportion of administrative costs such as phone or rent in a project budget,buttherearestricttermsandconditionsdetailingwhatisanacceptableexpenditureandwhatisnot. Project funding generally results in the funder retaining control of the content of services delivered by community based organisations. Project funding is typically shortterm and limits the ability of community basedorganisationstoplanforthelongterm. Provisionofcorefundingisnormallydefinedinaninstitutionaldocumentthatisdevelopedinaccordancewiththe organisationsneedsandwhichisapprovedbyarelevantorganisationalbodysuchastheboardorgeneralassembly. Numerator: Total number of community based organisations targeted for CSS with confirmed corefundingforatleast2yearsstartingatthetimeofreporting. Totalnumberoftargetedcommunitybasedorganisationsorallcommunity basedorganisationsinatargetedarea.

Denominator: Measurement:

Targetedcommunitybasedorganisationsarerequestedtoprovidetheinstitutionaldocumentdescribingthe agreement on the provision of corefunding. For the calculation of the numerator, only those community basedorganisationsthathavereachedanagreementtoreceivecorefundingforatleast2yearsormorefrom thetimeofreportingonwardsshouldbetakenintoconsiderationforthecalculationofthenumerator. Datasources: Frequency: Institutionaldocumentation,administrativerecords Annually

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(6.1) Number and percentage of community based organisations reporting no stockout of essential commoditiesduringthereportingperiod
Rationale Continuousavailabilityofessentialcommoditiesisabasicrequirementforservicedeliveryatthecommunity level.Thisindicatorintendstomeasureswhetherorganisationsworkingatthecommunitylevelhaveasupply management system in place that ensures this. Efficient supply management is needed to ensure that organisationsdonotrunoutofstocksofrequiredcommodities. Definitionoftheindicator Given the variety of country contexts, organisations and programmes, it is suggested to define essential commodities on a case by case basis in advance. Depending on the specific context, essential commodities mayincludebutarenotlimitedtothefollowing: 1. MedicinessuchasARVs,ACTs 2. Suppliessuchassyringes,condomsetc. 3. Bednets 4. Laboratoryreagents Numerator: Number of community based organisations targeted for CSS that report no stock outofessentialcommoditiesonthelastdayofthereportingperiod Denominator: Total number of targeted community based organisations or all community based organisations in a targeted area that require a predefined set of essential commoditiesinordertodeliverservices.

Measurement: Targetedorganisationsarerequestedtoreportwhethertheyexperiencedastockoutofoneormoreessential commodityonthelastdayofthereportingperiod. Datasources: Frequency: Administrativerecords Every3/6months

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(6.2) Number and percentage of community based organisations that keep accurate data for inventory management
Rationale This indicator determines the extent to which stock records are maintained. The presence of adequately maintained and accurate stock records contributes to proper management of essential commodities and estimationofneedandfacilitatesthereorderingoftheessentialcommodities. Definitionoftheindicator Numerator: Number of community based organisations targeted for CSS that keep accurate logisticsdataforinventorymanagement. Total number of targeted community based organisations or all community based organisations in a targeted area that require a predefined set of essential commoditiesinordertodeliverservices.

Denominator:

Measurement Alistofessentialcommoditiesisaprerequisite.Theinformationiscollectedthrougharepresentativesampled survey.Foreachoftheessentialcommodities,examinethedataonthestockcardandcountthephysicalstock andthencomparephysicalandrecordedstock.Theerrorratecanthenbeidentified.Theuserofthisindicator should determine in advance what an acceptable error rate is for the logistics data to be considered accurate. Datasources: Frequency: Survey/supervisionorevaluationvisits Annually

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(6.3) Number and percentage of community based organisations with staff or volunteers trained or re trainedinstock(inventory)managementinthepast12months
Rationale Capacitybuildingthrough training in stock(inventory) management enables community based organisations to manage stocks efficiently and to ensure the availability of quality medicines and other essential commodities. Definitionoftheindicator Thetrainingorretrainingshouldbeconductedinaccordancewithnationalrecommendedguidelines(where suchguidelinesexist). Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSthathaveatleast one staff member who received training or retraining in stock management accordingtonationalrecommendedguidelines(wheresuchguidelinesexist)during thelast12monthsatthetimeofreporting. Total number of targeted community based organisations or all community based organisations in a targeted area that require a predefined set of essential commoditiesinordertodeliverservices.

Denominator:

Limitation Thisindicatordoesnotmeasurethequalityofthetraining,nordoesitmeasuretheoutcomesofthetrainingin termsofthecompetenciesofindividualstrainedortheirjobperformance. Measurement

Targeted organisations are requested to submit appropriate administrative records to demonstrate the name(s) of staff and volunteers who received training or retraining in inventory management. For the calculation of the numerator, organisations will only be counted if at least one staff member or volunteer received training or retraining in inventory management in the last 12 months. Only staff members and volunteers that received training or retraining in the last 12 months and that are still working for the communitybasedorganisationatthetimeofreportingshouldbetakenintoconsiderationforthecalculation ofthenumerator. Datasources: Frequency: Appropriateadministrativerecords Every3/6months

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(6.4) Number and percentage of community based organisations that maintain adequate storage conditionsandhandlingproceduresforessentialcommodities
Rationale The quality of essential commodities is highly dependent on storage and handling capability. Tracking the standardsandproceduresforstorageandhandlingisthereforecriticalinensuringtheexistenceofadequate standardstoassuresafestorageandhandlingofessentialcommodities. Definitionoftheindicator Numerator: Total number of community based organisations targeted for CSS that maintain acceptablestorageconditionsandhandlingprocedures. Total number of targeted community based organisations or all community based organisations in a targeted area that require a predefined set of essential commoditiesinordertodeliverservices.

Denominator:

Measurement Itisessentialtohaveavailableachecklistofminimumcriteriaforadequatestorageconditionsandhandlingof essentialcommoditiesavailableattheorganisation.Suchachecklistshouldbedevelopedinordertousethis indicatorandshouldbebasedonWHOgoodstoragepractices(seeresourcesbelow)andnationalguidelines (where such guidelines exist). During a survey, supervision or evaluation visit, the items of the checklist for storageconditionsandhandlingofessentialcommoditiesareratedtrueorfalse.Forthecalculationofthe numeratoronlythoseorganisationsshouldbecountedthatrespondtruetoalltheitemsofthechecklist. Datasources: Frequency: Survey,supervisionorevaluationvisits Annually

Resources:WHOoperationalpackageforassessing,monitoringandevaluatingcountrypharmaceutical situations.Guideforcoordinatorsanddatacollectors.Geneva,WorldHealthOrganisation,2007 http://www.who.int/medicinedocs/index/assoc/s14877e/s14877e.pdf Amodelqualityassurancesystemforprocurementagencies.ModuleIV.Receiptandstorageofpurchased productsandappendix14.In:WHOExpertCommitteeonSpecificationsforPharmaceuticalPreparations: fortiethreport.Geneva,WorldHealthOrganisation,2006(WHOTechnicalReportSeries,No.937); http://whqlibdoc.who.int/trs/WHO_TRS_937_eng.pdf WHO,UNICEF,UNDP,UNFPAandWorldBank.Amodelqualityassurancesystemforprocurementagencies: recommendationsforqualityassurancesystemsfocusingonprequalificationofproductsandmanufacturers, purchasing,storageanddistributionofpharmaceuticalproducts.Geneva,WorldHealthOrganisation,2007 http://www.who.int/medicines/publications/ModelQualityAssurance.pdf

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(7.1) Number and percentage of community based organisations with the minimum capacity to deliver servicesaccordingtonationalguidelines(wheresuchguidelinesexist)
Rationale ThisindicatormeasuresthecapacityofcommunitybasedorganisationstoprovidequalityHIV,TBandmalaria servicesthatmeetnationalguidelines(wheresuchguidelinesexist). Definitionoftheindicator Theorganisationalcapacityrequiredtodeliverqualityservicesincludestechnicalandhumanresourcesaswell as financial, M&E and stock management. Given the variety of programmes, organisations and country contexts, there is a huge difference in capacity needs between actors. It is, therefore, recommended that countries define the minimum capacity requirements depending on their specific context. Please refer to national guidelines where these exist or to any other type of guideline. Implementers of CSS interventions should agree on the minimum capacity requirements in consultation with the targeted community based organisations. It is important to understand that the minimum capacity might vary across different types of organisations. If working with different types of organisations please ensure that minimum capacity requirementsaredefinedforallthesetypesoforganisations. Numerator: Total number of community based organisations targeted for CSS that have the minimumcapacitytodeliverHIV,TBormalariaservices. Totalnumberoftargetedcommunitybasedorganisations,orallcommunitybased organisationsinatargetedarea,thatdeliverservicesforHIV,TBormalaria. ThisindicatorshouldbecalculatedseparatelyforHIV,TBandmalaria.

Denominator:

Disaggregation: Measurement

Communitybasedorganisationsarerequestedtoreportwhethertheyhavetheminimumcapacitytodeliver HIV,TBormalariaservicesincompliancewiththedefinedstandardsforminimumcapacityagreedbetween theCSSimplementerandthetargetedorganisations. Datasources: Frequency: Resources Moreinformationregardingcapacityforservicedeliverycanbefoundatthefollowingsites: ForHIV:http://www.who.int/hiv/topics/en/index.html Formalaria:http://www.who.int/topics/malaria/en/ ForTB:http://www.who.int/tb/topics/en/ Administrativerecords Annually

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(7.2) NumberandpercentageofpeoplethathaveaccesstocommunitybasedHIV,TBormalariaservices inadefinedarea

Rationale ThisindicatorintendstomeasureaccesstoservicesprovidedbycommunitybasedorganisationsforHIV,TB andmalaria. Definitionoftheindicator Thisindicatorshouldfocusonallpeopleoraspecificpopulationsubgroupinadefinedareasuchasadistrict, aprovinceoracountry. Numerator: TotalnumberofindividualsthathaveaccesstocommunitybasedHIV,TBormalaria services. All people, or those belonging to a specific population subgroup, in the defined area. Bydisease,typeofserviceandlivingenvironment(ruralorurban).

Denominator:

Disaggregation: Limitation

Thisindicatordoesnotmeasurethequalityofservicesprovidedneitherequityinservicedelivery. Measurement ThisindicatorshouldbecalculatedseparatelyforeachtypeofHIV,TBandmalariaservice.Dataonthetotal numberoforganisationsthatofferspecificservicesandthepopulationstheyservecanbeobtainedthrough incountry mapping exercises. The relevant bodies that oversee the work done by community based organisationsneedtoplanandexecutetheseexercisesregularlytofacilitatetheassessmentprocess. Datasources: Frequency: Populationbasedsurvey 23years

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(8.1) Number and percentage of community based organisations with staff or volunteers who received trainingorretraininginmanagement,leadershiporaccountabilityinthelast12months
Rationale Skills in management, leadership and accountability are important drivers for effective governance of communitybasedorganisations.Thisindicatorprovidesvaluableinformationontheincreaseinorganisational capacity. Definitionoftheindicator The training or retraining in management, leadership and/or accountability should be conducted in accordancetonationallyrecommendedguidelines(wheresuchguidelinesexist). Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSthathaveatleast one staff member or volunteer who received training or retraining according to nationally recommended guidelines (where such guidelines exist) in management, leadershiporaccountabilityduringthelast12monthsandwhoisstillworkingfor thecommunitybasedorganisationatthetimeofreporting. Totalnumberoftargetedcommunitybasedorganisationsorallcommunity basedorganisationsinatargetedarea.

Denominator: Limitation

Thisindicatordoesnotmeasurethequalityofthetraining,nordoesitmeasuretheoutcomesofthetrainingin termsofthecompetenciesofindividualstrainedortheirjobperformance. Measurement

Targeted organisations are requested to submit training records which include the dates and names of the staff members and volunteers that received the training or retraining. Community based organisations will only be counted if at least one staff member or volunteer received training in management, leadership or accountabilityinthelast12months.Onlystaffmembersandvolunteersthatreceivedtrainingorretrainingin thelast12monthsandthatarestillworkingforthecommunitybasedorganisationatthetimeofreporting shouldbetakenintoconsiderationforthecalculationofthenumerator. Datasources: Frequency: Trainingrecords Every3/6months

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(8.2) Number and percentage of staff members and volunteers of community based organisations with writtentermsofreferenceanddefinedjobduties
Rationale Itisimportantthatallstaffmembersandvolunteersofcommunitybasedorganisationshavewrittentermsof references with job duties defined. Such documents describe the specific roles and responsibilities of each staffmemberandvolunteerandclarifyreportinglines. Definitionoftheindicator Termsofreferencenormallycontain: Theroleofthestaffmember/volunteer Theresponsibilitiesofthestaffmember/volunteer Keyresultsexpected

Theconditionsofthecontractincludingworkinghours,compensation,etc. Numerator: Totalnumberofstaffmembersandvolunteersthathavewrittentermsofreference withjobdutiesdefinedandthatworkfortargetedcommunitybasedorganisations atthetimeofreporting. Denominator: Total number of staff members and volunteers working for targeted community basedorganisationsatthetimeofreporting.

Measurement

Targetedcommunitybasedorganisationsarerequestedtoreportonthetotalnumberofstaffmembersand volunteers working for the organisation and should report if and how many of them have written terms of referencewithdefinedjobdutiesatthetimeofreporting. Datasources: Frequency: Administrativerecords,termsofreference Annually

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(8.3) Number and percentage of community based organisations that received technical support for institutionalstrengtheninginthelast12months
Rationale Many community based organisations have weak institutions and would benefit from technical support for institutional strengthening. Institutional strengthening supports community based organisations in strategic planning,decisionmakingandservicesdelivery. Definitionoftheindicator Technical support in the context of this indicator refers to cooperation between external experts and the organisations staff and volunteers for the assessment of existing institutions, development of a plan for institutionalstrengtheningandimplementationoftheplan. Technical support for institutional strengthening may include but is not limited to: administrative and managerial development, strategic planning, governance and leadership, programme and financial management, procurement and supply management, monitoring and evaluation of performance and developmentofacomputerizedinformationsystem. Numerator: Total number of community based organisations who report to have received technicalsupportforinstitutionalstrengtheninginthelast12months. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement Targeted organisations should be requested to report whether or not they received technical support for institutionalstrengtheninginthelast12months. Datasources: Frequency: Administrativerecords Annually

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(9.1) Number and percentage of community based organisations with at least one staff member or volunteerresponsibleformonitoringandevaluation
Rationale This indicator measures whether organisations that are working at the community level have a designated staff member or volunteer who is responsible for monitoring and evaluation. Monitoring and evaluation includes activities such as data collection, analysis and use to improve programme planning and decision making. Definitionoftheindicator Thisindicatormeasureswhethercommunitybasedorganisationshaveonestaffmemberorvolunteerwhois responsibleforallactivitiesrelatedtomonitoringandevaluation. Numerator: Total number of community based organisations targeted for CSS that have one staff member or volunteer responsible for monitoring and evaluation of the organisationatthetimeofreporting. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement: Targetedorganisationsarerequestedtoprovidethenameofthestaffmemberorvolunteerresponsibleforall monitoring and evaluation activities of the organisation as well as his or her terms of reference which describesthemonitoringandevaluationresponsibilities. Datasources: Frequency: Annualorganisationalreports;termsofreference Annually

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(9.2) Numberandpercentageofcommunitybasedorganisationsthatareimplementingacostedannual workplanwhichincludesmonitoringandevaluationactivities

Rationale Havingafunctionalcostedworkplaninplacewhichincludesmonitoringandevaluationactivitiesisimportant forcontributingtoeffectiveservicedeliveryforHIV,TBandmalaria.Agoodworkplanprovidesstructureand helpsinplanningandimplementationofoperations. Definitionoftheindicator Firstly,thisindicatormeasuresinthefirstplacetheexistenceofacostedannualworkplanthatincludesall activitiesconductedbytheorganisationincludingthoserelatedtomonitoringandevaluation.Secondly,this indicator measures whether the costed annual work plan is actually being implemented. A work plan is an operational plan which contains all operational activities of the organisation such as programmematic activities,monitoringandevaluationactivities,communication,advocacy,resourcemobilization,procurement andhumanresources.Afunctionalworkplanincludes: Alistofgoalsandobjectives(preferablyharmonizedwiththenationalstrategy); Alistofallactivitiesthatwillbeundertakenbytheorganisation.Allactivitiesshouldbelinkedtothe identifiedobjectives; Acleartimeframeshowingwhichactivitieswillbeimplementedwhen; Aresponsibleactorforeachoftheidentifiedactivities; Estimatedcostsofallactivities; Fundingsourcesforalloftheactivities.

Costed annual work plans of community based organisations should be developed in consultation with all relevantcommunitystakeholders. Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSthathaveacosted annual work plan in place which includes monitoring and evaluation activities and thatprovideevidencetodemonstratetheimplementationoftheplan. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement

Communitybasedorganisationsarerequestedtosubmittheircurrentcostedannualworkplanatthetimeof reporting. Targeted community based organisations are requested to provide some form of evidence demonstrating the implementation of monitoring and evaluation related activities according to the annual workplan.Thisevidencecouldbeprovidedintheformofareportorotherwrittendocumentation. Datasources: Frequency: Annualworkplan,implementationreports,otherdocumentation Annually

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(9.3) Number and percentage of community based organisations with at least one staff member or volunteer who received training or retraining in planning or M&E according to nationally recommendedguidelines(wheresuchguidelinesexist)inthelast12months
Rationale CapacitybuildingthroughtraininginplanningandM&Eenablestrainedindividualstogeneraterelevanthigh qualitydata,analyzethemandthentousethesedatatoimproveprogrammeplanninganddecisionmaking. ThisindicatorprovidesvaluableinformationontheincreaseinorganisationalcapacityinplanningandM&Eof HIV,TBandmalariaprogrammesatthecommunitylevel. Definitionoftheindicator Thetrainingorretrainingshouldbeconductedinaccordancewithnationallyrecommendedguidelines(where suchguidelinesexist). Organisationswillonlybecountedifatleastonestaffmemberorvolunteerreceivedtraininginplanningor M&Einthelast12months. Numerator: TotalnumberofcommunitybasedorganisationstargetedforCSSthathaveatleast one staff member or volunteer who received training according to nationally recommendedguidelines(wheresuchguidelinesexist)inplanningormonitoring& evaluationduringthelast12monthsatthetimeofreporting. Total number of targeted community based organisations or all community based organisationsinatargetedarea. BytraininginM&Eorplanning

Denominator:

Disaggregation: Limitation

Thisindicatordoesnotmeasurethequalityofthetraining,nordoesitmeasuretheoutcomesofthetrainingin termsofthecompetenciesofindividualstrainedortheirjobperformance. Measurement

Targeted organisations are requested to submit training records which include the names and dates of the staffmembersandvolunteersthatreceivedtrainingorretraininginM&Eorplanning.Forthecalculationof thenumerator,organisationswillonlybecountedifatleastonestaffmemberorvolunteerreceivedtraining or retraining in planning or M&E in the last 12 months. Only community based organisations with a staff memberorvolunteerthatreceivedtrainingorretraininginthelast12monthsandthatisstillworkingforthe communitybasedorganisationatthetimeofreportingshouldbetakenintoconsiderationforthecalculation ofthenumerator. Datasources: Frequency: Trainingrecords Every3/6months

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(9.4) Numberandpercentageofcommunitybasedorganisationsusingstandarddatacollectiontoolsand reportingformatsthatenablereportingtothenationalreportingsystem

Rationale Data collected at the community level is often not integrated in the national reporting system. Integrating communityleveldataintothenationalreportingsystemisimportantforprogrammeplanningandinformed decisionmaking.Thisindicatorintendstomeasuretowhatextentcommunitybasedorganisationsmakeuse ofstandarddatacollectiontoolsandreportingformatsthatfacilitatetheintegrationofcommunityleveldata intothenationalreportingsystem. Definitionoftheindicator Datacollectiontoolscanincludemanualprimarysourcedocuments,registersandbothmanualandelectronic databasesfordatacollection.Standardreportingformatsrefertothoserecommendedbynationalguidelines (wheresuchguidelinesexist). Toenabletheintegrationofcommunityleveldataintothenationalreportingsystem,itisimportantthatdata collection tools capture all relevant information that is required by the national reporting system. A description of what information should be captured is normally included in the national monitoring and evaluationplan. Numerator: Total number of community based organisations targeted for CSS that are using standard data collection tools and reporting formats that enable reporting to the designatedentityofthenationalreportingsystem. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement

Targetedorganisationsarerequestedtosubmitcopiesoftheirdatacollectiontools.Adeskreviewshouldbe conductedtoevaluatewhetherthedatacollectiontoolsusedbythetargetedorganisationsenablethemto report to the national reporting system. Constructive feedback should be provided. The use of standard reportingformatscanbeverifiedbythedesignatedentityofthenationalreportingsystem,bycountingthe numberofreportsreceivedinthestandardreportingformatoutofthetotalnumberofreportsreceived. Datasources: Frequency: Datacollectiontoolsandreportingformats Annually

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(9.5) Number and percentage of community based organisations conducting reviews of their own programmeperformanceinthelast3/6months
Rationale Regularreviewofprogrammeperformanceisimportantfororganisationstoidentifygapsandtoincreasethe efficiencyandqualityofservicesdelivered. Definitionoftheindicator This indicator measures whether community based organisations conduct regular reviews of their own programme performance. A good review of programme performance should take the following steps into consideration: Definitionofthereviewprocess; Discussionofeachoftheactivityareasregardingpastperformance,bestpractices,challengesand risks.

Preparationofanactionplanwhichidentifiesthenextstepstoaddresstheissuesraisedduringthe review. Performance reviews should be conducted every 3 or 6 months depending on the country context and reporting cycles. This indicator focuses on reviews conducted by the targeted organisations themselves on their own programme performance and does not refer to participation in larger review processes such as a jointnationalprogrammereview. Numerator: Total number of community based organisations targeted for CSS that have conductedareviewoftheirprogrammeperformanceinthelast3/6monthsatthe timeofreporting. Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Denominator:

Measurement

Communitybasedorganisationsarerequestedtoreportwhethertheyhaveconductedareviewoftheirown programmeperformanceinthelast3/6months.Theyshouldberequestedtosubmitasimpledocumented descriptionofthereviewprocesswhichincludes: Thenamesoftheparticipants; Asummaryoftheissuesraisedduringthereview;

Actionpointsaddressingtheissuesraisedduringthereview. Datasources: Documenteddescriptionofthereviewprocess Frequency: Every3/6months

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(10.1) Numberandpercentageofcommunitybasedorganisationswithadevelopedstrategicplancovering 3to5years

Rationale Astrategicplanhelpstoensurethatdeliveredservicescontributetolongtermgoalsandobjectives.Agood strategicplanprovidesavisionandstructureandsupportstheplanningandimplementationofoperations. Definitionoftheindicator Thisindicatorisintendedtomeasurewhethercommunitybasedorganisationshaveastrategicplaninplace, covering3to5years,whichisvalidatthetimeofreporting.Forexampleanorganisationthathasa5year strategicplaninplacecovering20062011wouldstillbecountedinthenumeratorin2010. Agoodstrategicplancontainsthefollowingelements: Avision Amissionstatement Criticalsuccessfactors Strategiesandactionstoachievedefinedobjectives

Aprioritizedimplementationschedule Numerator: Total number of community based organisations targeted for CSS that have a strategicplaninplace,coveringatotalperiodof3to5years,whichisstillvalidat thetimeofreporting. Denominator: Total number of targeted community based organisations or all community based organisationsinatargetedarea.

Measurement

Communitybasedorganisationsarerequestedtosubmitacopyoftheirstrategicplan. Datasources: Frequency: Strategicplans Annually

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7. USEFULRESOURCES
a) Sourcesofsupportandtechnicalassistance AfricanCouncilofAIDSServiceOrganisations(AfriCASO)http://www.africaso.net/ AIDS&RightsAllianceforSouthernAfricacapacitybuildinghttp://www.arasa.info/capacitybuilding AsiaPacificCouncilofAIDSServiceOrganisations(APCASO)http://www.apcaso.org/ AsianHarmReductionNetworkTechnicalAssistanceandCapacityBuildingUnit http://www.ahrn.net/index.php?option=content&task=view&id=2117&Itemid=2 AidspanguidestotheGlobalFundhttp://www.aidspan.org/index.php?page=guides CaribbeanHIV/AIDSRegionalTrainingNetwork(CHART)http://www.chartcaribbean.org/ CivilSocietyActionTeam(CSAT)http://www.icaso.org/csat.html EurasionHarmReductionNetwork(EHRN)trainingsandtechnicalassistancehttp://www.harm reduction.org/hub.html FundingforcivilsocietyresponsestoHIV/AIDSinTanzania:Status,problems,possibilities;CADREMay2008 http://www.cadre.org.za/node/192 GlobalNetworkofPeopleLivingwithHIV(GNP+)http://www.gnpplus.net/content/view/14/86/ LatinAmericanandtheCaribbeanCouncilofAIDSServiceOrganisation(LACCASO)http://www.laccaso.org/ MEASURE Evaluation Capacity Building Guides http://www.cpc.unc.edu/measure/tools/monitoring evaluationsystems/capacitybuildingguides/capacitybuildingguidesindex.html RollBackMalariaToolboxhttp://www.rollbackmalaria.org/toolbox/index.html StopTBTBTechnicalAssistanceMechanism(TEAM)http://www.stoptb.org/countries/tbteam/default.asp UNAIDSTechnicalSupportFacilitieshttp://www.unaids.org/en/CountryResponses/TechnicalSupport/TSF/ b) Otherinformationsources,includingthosereferencedintheCSSFramework Amodelqualityassurancesystemforprocurementagencies.ModuleIV.Receiptandstorageofpurchased products:WHOExpertCommitteeonSpecificationsforPharmaceuticalPreparations:40threport;WHO Geneva2006http://whqlibdoc.who.int/trs/WHO_TRS_937_eng.pdf Amodelqualityassurancesystemforprocurementagencies:recommendationsforqualityassurancesystems focusingonprequalificationofproductsandmanufacturers,purchasing,storageanddistributionof pharmaceuticalproducts;WHO/UNICEF/UNDP/UNFPA/WorldBank2007 http://www.who.int/medicines/publications/ModelQualityAssurance.pdf AbujaDeclarationandPlanofActionhttp://www.rollbackmalaria.org/docs/abuja_declaration_final.htm Advocacy,communication&socialmobilisation(ACSM)fortuberculosiscontrolahandbookforcountry programmes;StopTBPartnership2007http://whqlibdoc.who.int/publications/2007/9789241596183_eng.pdf AmsterdamDeclarationtoStopTB http://www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf Community directed interventions for major health problems in Africa. A multicountry study; WHO 2008 http://apps.who.int/tdr/svc/publications/tdrresearchpublications/communitydirectedinterventionshealth problems

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CommunitySystemsStrengtheningCivilSocietyConsultation;InternationalHIV/AIDSAlliance/ICASO2010 http://www.aidsalliance.org/Pagedetails.aspx?id=407 CivilSocietySupportandTreatmentAccess;FakoyaA,AbdefadilL,PublicServiceReview:International Development#14,June2009http://www.publicservice.co.uk/article.asp?publication=International Development&id=391&content_name=Treatmentaccess&article=12197 Communityinvolvementinrollingbackmalaria;RollBackMalaria/WHO2002 http://www.rollbackmalaria.org/cmc_upload/0/000/016/247/community_involvement.pdf Communityinvolvementintuberculosiscareandprevention:Guidingprinciplesandrecommendationsbased onaWHOreview;WHO2008 http://www.stoptb.org/resource_center/assets/documents/Community%20involvement%20in%20TB%20care %20and%20prevention.pdf CommunityOrganizingandCommunityBuildingforHealth;MeredithMinkler(2004)RutgersUniversityPress http://rutgerspress.rutgers.edu/acatalog/__Community_Organizing_and_Community_Building_for__664.html DeclarationofAlmaAtaInternationalconferenceonprimaryhealthcare1978; http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf DeclarationofCommitmentonHIV/AIDShttp://www.unaids.org/en/AboutUNAIDS/Goals/UNGASS/default.asp Exploringtheconceptofcommunity:implicationsforNGOmanagement;JodeBerry2002,LondonSchoolof Economicshttp://www.lse.ac.uk/collections/CCS/pdf/IWP/IWP8deberry.PDF FundingforcivilsocietyresponsestoHIV/AIDSinTanzania:Status,problems,possibilities;CADREMay2008 http://www.cadre.org.za/node/192 Gender,HealthandMalaria;WHO/RBMJune2007; http://www.rollbackmalaria.org/globaladvocacy/docs/WHOinfosheet.pdf GlobalHIVM&Einformationwebsite: http://www.globalhivmeinfo.org/DigitalLibrary/Pages/12%20Components%20HIV%20Evaluation%20Research %20and%20Learning%20Resources.aspx Guidelinesforthestorageofessentialmedicinesandotherhealthcommodities;JSIDELIVER2003 http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/GuidStorEsse_Pock.pdf Handbookofsupplymanagementatfirstlevelhealthcarefacilities;WHO2007 http://www.who.int/hiv/amds/HandbookFeb2007.pdf HIVMonitoring&EvaluationResourceLibrary;WorldBankGAMETwebsite http://gametlibrary.worldbank.org/pages/12_1)HIVM_ESystems12components_English.asp Homeiswherethecareis.TheroleofcommunitiesindeliveringHIVtreatmentcareandsupport;AbdefadilL, FakoyaA,PublicServiceReview:InternationalDevelopment#15,September2009 http://www.publicservice.co.uk/pub_contents.asp?id=401&publication=International Development&content=3850&content_name=Health IncreasingCivilSocietyImpactontheGlobalFundtoFightAIDS,TuberculosisandMalaria:StrategicOptions andDeliberations;BrookKBaker,ICASO2007 http://www.icaso.org/resources/CS_Report_Policy_Paper_Jan07.pdf IndicatorStandards:OperationalGuidelinesforSelectingIndicatorsfortheHIVResponseindicator;UNAIDS MERG,January2010 http://www.globalhivmeinfo.org/AgencySites/MERG%20Resources/MERG%20Indicator%20Standards_Operati onal%20Guidelines.pdf ManagingTBmedicinesattheprimarylevel;MSHRPMPlus2008 http://erc.msh.org/toolkit/toolkitfiles/file/TBPrimaryLevelGuideApril2008_finalEnglish.pdf MillenniumDevelopmentGoalshttp://www.undp.org/mdg/basics.shtml

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ModelsforFundingandCoordinatingCommunityLevelResponsestoHIV/AIDS;CADRE2007 http://www.cadre.org.za/node/198 MonitoringandEvaluationToolkitHIV,TuberculosisandMalariaandHealthSystemsStrengthening,3rd edition;TheGlobalFund2009;http://www.theglobalfund.org/documents/me/M_E_Toolkit.pdf ModelsforFundingandCoordinatingCommunityLevelResponsestoHIV/AIDS;CADRE2007 http://www.cadre.org.za/node/198 OperationsManualforDeliveryofHIVPrevention,CareandTreatmentatPrimaryHealthCentresinHigh Prevalence,ResourceConstrainedSettings;WHOIMAIDec2008; http://www.who.int/hiv/pub/imai/operations_manual/en/ OttawaCharterforHealthPromotion;FirstInternationalConferenceonHealthPromotion;WHO1986 http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf Partnershipwork:thehealthservicecommunityinterfacefortheprevention,careandtreatmentofHIV/AIDS; WHO2002http://www.who.int/hiv/pub/prev_care/en/37564_OMS_interieur.pdf Procurement&SupplyManagementToolbox;http://www.psmtoolbox.org/en/ ProjectCycleManagement:CBOTrainingToolkit;COREInitiative2006 http://www.coreinitiative.org/Resources/Publications/ProjectCycleManagementToolkit.pdf RatesofvirologicalfailureinpatientstreatedinahomebasedversusafacilitybasedHIVcaremodelinJinja, southeastUganda:aclusterrandomisedequivalencetrial;JaffarS,BAmuronetal(2009)Lancet http://www.thelancet.com/journals/lancet/article/PIIS01406736(09)616743/abstract SelfAssessmenttoolsonHIV,malariaandothercommunityissues;TheConstellation2008 http://www.communitylifecompetence.org/en/94resources SupportingcommunitybasedresponsestoAIDS:AguidancetoolforincludingCommunitySystems StrengtheninginGlobalFundproposals;UNAIDS,January2009; http://data.unaids.org/pub/Manual/2009/20090218_jc1667_css_guidance_tool_en.pdf StrengtheningCommunityHealthSystems:Perceptionsandresponsestochangingcommunityneeds;CADRE 2007.http://www.cadre.org.za/node/197 Supportforcollaborationbetweengovernmentandcivilsociety:thetwintrackapproachtostrengtheningthe nationalresponsetoHIVandAIDSinKenya;FuturesGroupEurope2009 http://www.futuresgroup.com/wpcontent/uploads/2009/11/FGEBriefingPaperNovember2009.pdf TechnicalGuideforcountriestosettargetsforuniversalaccesstoHIVprevention,treatmentandcarefor injectingdrugusers;WHO/UNODC/UNAIDS2009:http://www.who.int/hiv/pub/idu/targetsetting/en/ TheGlobalFundInformationNotesFactSheets: CommunitySystemsStrengtheningInformationNote: http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_CSS_en.pdf FactSheet:theGlobalFundsapproachtohealthsystemsstrengthening: http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_HSS_en.pdf FactSheet:Women,Girls,andGenderEquality:: http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_Gender_en.pdf: FactSheet:SexualMinoritiesinthecontextoftheHIVepidemic: http://www.theglobalfund.org/documents/rounds/10/R10_InfoNote_SOGI_en.pdf TheGlobalFundMonitoring,EvaluationandOperationsResearchresources: Frameworkforoperationsresearch;TheGlobalFund2009; http://www.theglobalfund.org/documents/me/FrameworkForOperationsResearch.pdf Monitoringandevaluationplanguideline;TheGlobalFund2010; http://www.theglobalfund.org/documents/me/M_E_Plan_Guidelines_en.pdf Monitoringandevaluationselfassessment;TheGlobalFund2007; http://www.theglobalfund.org/documents/me/M_E_Systems_Strengthening_Tool.pdf

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TheMostSignificantChange(MSC)Techniqueaguidetoitsuse;RDavies&JDart2005 http://www.mande.co.uk/docs/MSCGuide.pdf TheWorldHealthReport2008PrimaryHealthCareNowMoreThanEver http://www.who.int/whr/2008/en/index.html UNGASSGuidelinesfor2010reporting;UNAIDS2009 http://www.unaids.org/en/KnowledgeCentre/Resources/FeatureStories/archive/2009/20090331_UNGASS201 0.asp WHOoperationalpackageforassessing,monitoringandevaluatingcountrypharmaceuticalsituations.Guide forcoordinatorsanddatacollectors;WHO2007 http://www.who.int/medicinedocs/index/assoc/s14877e/s14877e.pdf WHOTheDeterminantsofHealthhttp://www.who.int/hia/evidence/doh/en/index.html WHOHIVwebsite:http://www.who.int/hiv/topics/en/index.html WHOMalariawebsite:http://www.who.int/topics/malaria/en/ WHOTBwebsite:http://www.who.int/tb/topics/en/