Information Note for the Global Fund’s
Investments in Health and Community
Systems Strengthening
Draft, January 28, 2013
This draft was developed by an HSS/CSS working group and incorporates comments from wider
HSS, CSS, gender and human rights communities.
It will be reviewed by HIV, TB and malaria communities before submitting to the Global Fund
leadership for review and approval
2013
Contents
Acknowledgements ............................................................................................................................. 3
Executive Summary ............................................................................................................................. 4
1.
Introduction ................................................................................................................................. 6
1.1.
What is this document for? ............................................................................................................. 6
1.2.
Why Health and Community Systems Strengthening? .................................................................. 6
1.3.
The Global Fund’s investments in Health and Community Systems Strengthening ...................... 7
1.4.
The basis for cross-cutting HCSS funding applications ................................................................. 8
2.
Interactions between health and community systems ....................................................................... 9
3.
Priorities for cross-cutting HCSS investments ...............................................................................13
4. Links between Global Fund investments in HIV/AIDS, tuberculosis and malaria programs and crosscutting HCSS ..................................................................................................................................... 17
5.
Important considerations for developing cross-cutting HCSS funding requests ............................... 23
5.1. Entry points for health and community systems strengthening ......................................................... 23
5.2. Addressing common needs across HIV/AIDS, tuberculosis and malaria programs ......................... 23
5.3. Diagnosing underlying causes of poor systems performance............................................................ 23
5.4. Seeking synergies with health outcomes beyond HIV/AIDS, tuberculosis and malaria ................... 23
5.5. Preempting potential side-effects of cross-cutting HCSS interventions ............................................ 24
5.6. Applying evidence-based interventions and innovative approaches ................................................. 24
5.7. Integrating outcome and impact measurement in cross-cutting HCSS funding requests .................. 24
6.
Integrating Gender, Human Rights, RMNCH and Other Cross-cutting Issues in HCSS ................... 24
Annex A: Indicative scope of Global Fund’s investments in HCSS ....................................................... 26
2
Acknowledgements
This document was developed by an inter-agency working group composed of:
George Shakarishvili, The Global Fund
Mauro Guarinieri, The Global Fund
Meg Davis, The Global Fund
Michael O’Connor, The Global Fund
Motoko Seko, The Global Fund
Bruno Bouchet, FHI-360
Matt Greenall, ICASO
Daniel Kraushaar, Management Sciences for Health
Gitau Mburu, International HIV/AIDS Alliance
Thierry Mertens, WHO
Paolo Piva, WHO
Denis Porignon, WHO
David Traynor, Communities Delegation to the Global Fund Board
David Weakliam, Irish Aid
We are grateful for valuable comments and suggestions received from: George Ayala, Nicolas
Bidault, Karen Cavanaugh, Martin Choo, Tarek Elshimi, Bob Emrey, Tim Evans, Louis da Gama,
Robin Gorna, James Heiby, Mai Hijazi, Sowmya Kadandale, Nicole Klingen, Lisa Luchsinger,
Sigrun Mogedal, Anders Nordstrom, Anton Ofield-Kerr, Bola Oyeledun, Todd Page, Mike
Podmore, Pascal Rodriguez, David Ruiz, Tore Rose, LiannaSarkisi, Gerard Schmets, Bakuti
Shengelia, Ken Sklaw, Scott Stewart, Raminta Stuikyte, David Wendt, Shona Wynd, Rachel
Yates.
3
Executive Summary
The Global Fund has provided financial support for cross-cutting Health Systems Strengthening
(HSS) interventions for some years, and has also supported Community Systems Strengthening
(CSS) through disease specific grants. Under the New Funding Model, being phased in during
2013, cross-cutting support will be available for both HSS and CSS as an integrated approach to
systems strengthening. By developing this approach, the Global Fund is recognizing that
effective responses to HIV/AIDS, tuberculosis and malaria, and improved health outcomes in
general, are produced by a complex system of institutions, organizations and sectors. The HCSS
approach implies that effective investments in HSS and CSS are interdependent: not only do
health systems and community systems intersect and complement each other, but the role of one
in a given context is largely dependent on the role of the other. The cross-cutting HCSS approach
therefore encourages HSS and CSS planners to evaluate the entire complex system as a basis for
developing funding requests that cover the range of health and community systems strengthening
needs.
Why does the Global Fund invest in cross-cutting HCSS?
 Strongly performing systems are a necessary prerequisite for effective implementation of
HIV/AIDS, tuberculosis and malaria programs that are central to the Global Fund’s mandate. The
Global Fund’s investments in cross-cutting HCSS are therefore essential complements to core
investments in HIV/AIDS, tuberculosis and malaria programs. Investments in HCSS strengthen
national systems and policies so as to maximize impact and to ensure long-term sustainability of
health outcomes across disease programs, as well as improving service delivery for other health
issues. By investing in HCSS, the Global Fund fulfills its mandate - to fight the three diseases –
by supporting the creation of an enabling environment, within which HIV/AIDS, tuberculosis and
malaria programs can be implemented more effectively, efficiently and equitably. Cross-cutting
HCSS investments must support national systems as a common public good. Although the
investments should primarily improve efforts to fight the three diseases, cross-cutting HCSS
interventions that also improve health outcomes beyond them are encouraged. Cross-cutting
HCSS investments foster synergies between multiple health programs and support their integration
into a common national system.
What do cross-cutting HCSS investments achieve?
 At the operational level, cross-cutting HCSS investments provide necessary inputs (e.g. salaries,
supplies) where domestic resources are not sufficient to operate the system at minimally
acceptable standards. This ensures uninterrupted functioning of the system’s core components,
which are essential for HIV/AIDS, tuberculosis and malaria programs.
 At the planning/management level, cross-cutting HCSS investments improve the organization,
management, capacity, set up and funding of discrete parts (institutions or subsystems) of the
system, which are essential to the effective functioning of health programs, notably for
HIV/AIDS, tuberculosis and malaria. These investments strengthen the system’s capacity and their
effect is expected to be sustained beyond the life-time of the Global Fund’s funding;
 To a limited extent, cross-cutting HCSS investments may also be directed at the inter-sectoral
level, to address gaps in State functions or policies and laws that adversely affect health and
community systems, and that consequently interfere with effective delivery of HIV/AIDS,
tuberculosis and malaria programs (e.g. public financial management, civil service,
decentralization arrangements in federal states, discriminatory policies or practices within health
systems, the ability of key affected populations to establish and develop networks to represent
them in policy advocacy, etc.)
4
This document is intended to inform applications for cross-cutting health and community systems
strengthening funding (HCSS). Cross-cutting support helps to improve the performance of
HIV/AIDS, tuberculosis and malaria programs as well as more broadly strengthening the systems
and mechanisms that contribute to fighting diseases and improving health.
The document is intended to clarify the rationale for and objectives of the Global Fund’s crosscutting HCSS investments; explains the intersections and interactions between health and
community systems; identifies priorities for Global Fund support to cross-cutting HCSS and the
scope of support available from the Global Fund in this area; and points out a number of
important considerations for developing successful funding requests, including the importance of
addressing gender, human rights and other cross-cutting issues which are central to the Global
Fund’s mandate and which are essential for effective programs. It also intends to help applicants
to highlight links between cross-cutting HCSS interventions and disease-specific interventions
that have a spillover effect of strengthening systems.
Applicants developing disease-specific funding requests may find this Note useful for framing the
systems-related components of their applications. However, they should primarily refer to the
disease specific guidance in developing applications for disease grants.
5
1. Introduction
1.1.
What is this document for?
This document is intended to inform applications for cross-cutting health and community systems
strengthening funding (HCSS). Cross-cutting HCSS helps to improve the performance of
HIV/AIDS, tuberculosis and malaria programs as well as more broadly strengthening the systems
and mechanisms that contribute to fighting diseases and improving health. The document clarifies
the rationale for and objectives of the Global Fund’s cross-cutting HCSS investments, identifies
the scope of support available from the Global Fund in this area and points out important
considerations for developing successful funding requests. It also helps applicants highlight links
between cross-cutting HCSS interventions and disease programs.
The document is designed as a technical reference to inform one of the main components of the
Global Fund’s New Funding Model - country dialogue between national stakeholders,
communities affected by the three diseases, technical partners, the Global Fund and other donors.
The document helps identify strategic, high-impact interventions that will positively impact the
environment (i.e. the health and community systems) in which HIV/AIDS, tuberculosis, and
malaria programs operate, and which help improve health outcomes more generally.
In addition to informing the content of cross-cutting HCSS funding requests, the document may
also be used by the Global Fund’s Technical Review Panel (TRP) in reviewing requests, and the
Global Fund Secretariat, applicant countries, and technical partners, in considering options for
reprogramming the HSS and CSS components of existing Global Fund grants.
1.2.
Why Health and Community Systems Strengthening?
This information note captures a number of important shifts in the Global Fund’s approach to
supporting health and community systems strengthening:
 Under the Global Fund’s previous funding model, cross-cutting funding (i.e. funding
across the three diseases) was only available for health systems strengthening. Under the
New Funding Model applicants will now be able to submit requests for HSS and CSS
interventions as an integrated approach to cross-cutting systems strengthening.
 By developing the concept of “Health and Community Systems Strengthening”, the Global
Fund is recognizing that effective responses to HIV/AIDS, tuberculosis and malaria are
produced by a complex system of institutions, organizations and sectors. The HCSS
approach implies that effective investments in HSS and CSS are interdependent: not only
do health systems and community systems intersect and complement each other, but the
role of one in a given context is largely dependent on the role of the other. The crosscutting HCSS approach therefore encourages HSS and CSS planners to evaluate the entire
complex system as a basis for developing funding requests that cover the range of health
and community systems strengthening needs.
 Although cross-cutting HCSS funding encourages a broader approach to assessing and
strengthening systems to fight HIV/AIDS, tuberculosis and malaria, the Global Fund also
recognizes that, although they intersect in many of their functions, health and community
systems are different in their nature, in the approaches for implementation, and in the types
of organizations involved. In the same way that the Global Fund encourages dual-track
financing for disease-specific grants, it is expected that cross-cutting HCSS grants will
6
also employ the most appropriate implementation arrangements, including dual-track
financing and civil society led-implementation. Applicants are encouraged to also refer to
other documents such as the Community System Strengthening Framework, that remains
the key reference for developing the role of key affected populations and communities,
community organizations and networks, and public- or private-sector actors that work in
partnership at the community level, in the design, delivery, monitoring and evaluation of
services and activities aimed at improving health1.
 While this Information Note is designed to support applicants developing cross-cutting
HCSS funding requests, the Global Fund will also continue to support interventions
within disease-specific funding requests, which may also have the spillover effect of
strengthening health and community systems. As such, applicants developing diseasespecific funding requests may find this Note useful for framing the systems-related
components of their applications. However, they should primarily refer to the disease
specific guidance in developing their applications.
1.3.
The Global Fund’s investments in Health and Community Systems
Strengthening
The Global Fund Strategy for 2012-2016, Investing for Impact, calls for better alignment of
Global Fund investments with national systems and structures. The term “national systems” refers
to all country systems and includes both government and non-government domains. Hence,
“cross-cutting Health and Community Systems Strengthening” implies that:
(i)
The impact of these investments goes beyond what is considered to be the formal
health sector and encompass the community, private and informal sectors. In order to
do this effectively, investments must take into account country specificities in the roles
various actors play in the response to HIV/AIDS, tuberculosis and malaria, and health
in general;
(ii)
The impact of investments goes beyond impact on a single disease, as these
investments strengthen national systems that contribute to health outcomes more
generally;
(iii)
The impact of investments is not limited to the strengthening of functions and
components of the formal health system, since they also strengthen functions,
components and actors within communities (the “community system”) that contribute
to improved health outcomes.
Investments in cross-cutting HCSS are, in many cases, a necessary complement to the Global
Fund’s core investments in HIV/AIDS, tuberculosis and malaria programs. While disease grants
fund the provision of preventive, diagnostic, treatment, care and support services, as well as
supporting community mobilization and critical disease-specific enablers, cross-cutting HCSS
investments address system-wide constraints that affect efforts to combat the three diseases. The
objectives of the Global Fund’s cross-cutting HCSS investments are as follows:
(i)
To foster synergies between various health, social and community development
programs, with a special focus on disease programs supported by the Global Fund, and
1http://www.theglobalfund.org/documents/civil_society/CivilSociety_CommunitySystemsStrengthening_
Framework_en/ (pdf)
7
to ensure that disease programs are properly integrated into health and community
systems;
(ii)
To support, scale-up and improve quality and equity of service delivery, to strengthen
and build capacity of human resources for health, and to support integrated responses
to HIV/AIDS, tuberculosis, and malaria, and synergies with other health and
community services (in particular those related to sexual and reproductive health and
rights, maternal, neonatal and child health);
(iii)
To provide essential support, including capacity building, to health and community
systems and sub-systems, such as those that relate to health information, procurement
and supply chain management, public financial management, civil service, governance
and accountability, networks and linkages between different actors and service
providers, health equity, community based, private and informal service provision,
community mobilization, and human rights of people most affected by AIDS,
tuberculosis and malaria;
(iv)
To support efforts aimed at reforming and refining legal, policy, regulatory and
financial contexts for increased transparency, equity, sustainability and efficiency of
health services and outcomes, and to ensure enabling environments for efforts to fight
AIDS, tuberculosis and malaria;
(v)
To support efforts to engage communities in the planning, delivery and monitoring of
services and systems to ensure they meet their needs, are respectful of their rights, and
help fulfill the right to health.
Specific HCSS interventions supported by the Global Fund will vary from country to country, as
they will be based on the specific needs and contexts. Annex A provides an indicative list of
interventions and activities that can be supported by HCSS grants.
1.4.
The basis for cross-cutting HCSS funding applications
Cross-cutting HCSS funding requests should be informed by a thorough analysis of health and
community systems needs across the three disease programs, which identifies systemic
bottlenecks that are relevant to efforts to respond to HIV/AIDS, tuberculosis and malaria, and
which maps the current availability of resources to address them. Development of HCSS funding
requests and prioritization of interventions based on a thorough gap analysis are the responsibility
of applicants, and, similarly to disease-specific grants, the Global Fund requires that cross-cutting
HCSS funding requests be based on inclusive, multi-stakeholder processes that address all levels
of the health and community systems.
Where possible, the process of analyzing HCSS gaps and developing a cross-cutting HCSS
funding request to the Global Fund should build on existing mechanisms, such, as for example,
the Joint Assessment of National Strategy (JANS) where multiple donors, led by the host country,
discuss their respective financial support for supporting the implementation of the national health
strategy.
The Global Fund recognizes, however, that health systems analyses, including JANS, focus on
formal health systems, and that the role of community systems within health systems and as
complements to health systems is inadequately recognized. There is therefore a need to introduce
8
processes which enable community system stakeholders to engage effectively in these analytical
and planning processes, and to develop and adapt tools that can effectively capture the role played
by community systems and the weaknesses or gaps that should be addressed in cross-cutting
HCSS funding requests. Ensuring a balanced health and community systems approach is essential.
The process for developing cross-cutting HCSS funding requests should also be closely linked to
analyses of HIV/AIDS, tuberculosis and malaria programs and to processes for developing
HIV/AIDS, tuberculosis and malaria funding applications to the Global Fund. A joint analysis of
the different programs and funding requests is necessary to ensure that systems strengthening
efforts are not duplicated or neglected, and that they are incorporated in the most appropriate
funding request.
Multi-country and regional applications for cross-cutting HCSS funding will be considered.
However, given the complexity of defining systems that span multiple countries, it is advised that
potential applicants discuss this approach with the Global Fund prior to preparing a funding
request.
2. Interactions between health and community systems
Improved health outcomes result from a range of policies, services, and other activities, which are
put in place by a wide range of actors. Together, they form a complex system, which includes not
only government or public health systems (made up of health facilities, regulatory and governance
bodies, and state-employed health care professionals), but also other sectors and actors within
communities and the private sector which are just as important to efforts to improve health
outcomes.
Community systems are structures and mechanisms through which community members,
community-based organizations and other actors coordinate and deliver their responses to the
challenges and needs they face2. Community organizations have a unique ability to identify,
understand and respond quickly to the needs of communities and individuals who are made
vulnerable as a result of social and structural factors, and who are affected by inequitable access
to health and other basic services. They often play a role in delivering services (particularly non
facility-based health services, and other social services), and they are also essential to ensuring
that formal health systems are responsive to needs, in particular the needs of marginalized groups.
In some contexts, community actors have to operate outside of mainstream health systems in
order to protect the health and human rights of people who are marginalized– for example,
undocumented migrants, sex workers, sexual minorities or people who use drugs.
Strong community systems play an important role in facilitating community participation in:
design, implementation and evaluation of programs and services; advocacy; creation of demand
for good-quality health services and equitable access ; addressing broader determinants of health
including gender inequalities and human rights; and promoting meaningful community
engagement in health-related governance, oversight and accountability.
As such, community action on health is an important complement to clinical or facility based
health services, as it helps to ensure they reach the right people and that they have the maximum
impact, and by addressing broader determinants of health. A multi-country evaluation of
community based responses conducted by the World Bank showed strong causal evidence that
2Adapted
from: The Global Fund to fight HIV, TB and Malaria. Community Systems Strengthening
Framework. 2011 revision.
9
specific community interventions can affect epidemic trends through increased knowledge, and
increased access to and use of prevention and treatment services3. Support to community systems
also builds ownership of health problems, and through this ownership communities originate
solutions and play an important role in implementing them.
The health system, which defines and regulates the provision of HIV/AIDS, TB, malaria services,
as well as those of other priority national health programs, is a complex system where political
commitments, human resources, laws, regulations, fiscal constraints, financial management,
external aid and national budgetary processes and allocations, all interact to impact on the
efficiency and efficacy of service delivery and ultimately on health outcomes Those multiple
processes, sub-systems and actors constantly and continuously interact making the system a
multidimensional dynamic entity, made up of interconnected and interdependent elements that
continuously change in response to external events, inputs and demands (Figure 1).
Figure 1: The continuum from political commitments to outcomes (source - WHO)
Although health systems and community systems are defined separately above, the two systems
are not mutually exclusive. Indeed there is significant overlap, as community or civil society
actors are often involved in providing health services, and similarly, employees of state health
systems often have a strong community focus (for instance, state-employed community health
workers).
Community systems are therefore both components of and complementary to health systems.
Understanding the interdependency of formal health systems and community systems is important
in guiding investments for better outcomes in the HIV/AIDS, tuberculosis and malaria, and
beyond (Figure 2).
3World
Bank.Evaluation of Community Responses to HIV and AIDS 2012
10
Social,cultural,
economic, legal and polictical
environments
health
actors
community
actors
Output
Overlap, synergies & cooperation
between community & health
systems
that lead to:
Develop & manage
Resulting
in:
Health
Outcomes
Enablers
Systems
which in turn contribute to:
Deliver
Health impact
Activities
and
services
Figure 2: Strengthening health and community systems for scaled-up, good-quality, sustainable
impacts on health4
Table 1 (below) provides further detailed examples of how certain functions that are necessary for
improving health outcomes require a combination of interventions delivered from both
community systems and (formal) health systems perspectives. These interventions work in
combination to achieve health outcomes. Moreover, the complementarity between community
and health systems is most effective when there are strong referral and feedback mechanisms
between the two.
4Adapted
from Community Systems Strengthening Framework (Global Fund, 2011)
11
Examples
of
Functions
Care and
treatment
Examples of Interventions within
Community systems


Examples of Interventions
within Health Systems
Home based care and support,
adherence counselling (including in
health facilities)
Provision of services in prisons and
other closed settings
Community outreach, education and
information exchange, communication
and distribution of commodities
Community level monitoring of access,
stigma, human rights violations.
Advocacy with government for legal
protections

Provision of treatment at health facilities

Poverty reduction; social protection
and livelihood support; access to
education; gender transformative
programming; programming promoting
rights; combating misinformation,
discrimination, stigma and violence

Collaboration between Ministry of
health and Ministry of Education on
school-based health promotion programs
Development and implementation of
non-discrimination policies
Training and sensitization of health
professionals
Ensuring health management
information systems are able to assess
equity, particularly related to gender and
vulnerable community
Linking with other sectors such as social
welfare and protection, justice,
education, women, children and family,
women, children and family;
Promotion of gender transformative
programming within the health sector
and with other sectors;
Ensuring inclusion of community actors
in planning and implementation and
evaluation of health system activities
Developing regulations for health
worker retention in hard-to-reach areas
Health
promotion

Equity,
gender
and
human
rights

Addressin
g social
determina
nts of
health

Enhancing
systems
capacity

Building organizational capacity of
community organizations


Building community health workers
(including service providers) and social
welfare capacity
Organizational capacity building
Community worker (including
volunteer) support and retention
programming
Monitoring, documenting and
evaluating community interventions

Social mobilization, building
community linkages, collaboration and
coordination
Developing referral mechanisms
between different components of health
and community systems













Strengthening information and M&E
systems through development of (sex
and age disaggregated) indicators and
reporting
Developing organizational and facility
management systems
Developing referral mechanisms
between different components of health
and community systems
Table 1: Interactions and complementarity between health and community systems
12
This interdependence underscores the mandate of the Global Fund to strengthen health and
community systems for the effective delivery of HIV/AIDS, tuberculosis and malaria programs.
Strengthening both health and community systems is essential in bringing all actors and system
components into full partnership.
The Global Fund acknowledges that there is a power imbalance between institutional and
community actors, that institutional and governmental actors are not always committed to
empowering and involving community actors, and that at times they are unwilling to support,
recognize or endorse community led services and activities. The Global Fund plans to help to
address this imbalance in two ways. Firstly, as noted above, the Global Fund requires that all
cross-cutting HCSS funding requests be based on a country dialogue through which all actors are
meaningfully represented; and the Global Fund will aim to ensure that there is an appropriate
distribution of resources between different actors. This will be properly monitored as part of the
transition to the New Funding Model.
Secondly, the Global Fund will help address the imbalance through its investments in crosscutting HCSS, as well as through investments in disease-specific programs. As noted above, CSS
has not explicitly been considered for cross-cutting funding requests by the Global Fund until
now. The Global Fund believes that through a strong focus on building organizational and human
resource capacity, and on ensuring that sufficient financial resources are provided to organizations
working at the community level in a stable, predictable way, the role of community systems will
increasingly be recognized and promoted at national level. The Global Fund also recognizes that
as a basic element of community systems strengthening, civil society organizations need to be
able to legally register and establish organizations and networks. Both organizations and
individuals have the right to share health information and to express opinions about laws and
policies, as well as to gather documentation to monitor their implementation. Thus, funding for
CSS will aim to build capacity of community-led organizations and networks of key affected
populations to register and establish sustainable institutions, to coordinate their work at the local
and national levels, to gather documentation and publish results and recommendations on health
and human rights, and to participate effectively in CCMs and in other policy and advocacy
forums.
3. Priorities for cross-cutting HCSS investments
The Global Fund’s investments in cross-cutting HCSS will address system bottlenecks and
weaknesses at the operational, planning/management and at the inter-sectoral levels:

At the operational level, system weaknesses and bottlenecks are caused by an overall lack of
system inputs – for instance in low-income countries, where domestic resources are not
sufficient to operate systems at minimally acceptable standards. HCSS investments at the
operational level are mostly inputs that will allow for smoother, uninterrupted functioning of
the system’s core components, and might better be defined as “system support” than “system
strengthening”, with the implication that such investments may not result in sustainable
outcomes beyond the lifetime of the program. When requesting funding for such investments,
applications should demonstrate that no other funding sources are available for providing the
inputs in question. If such investments benefit only one disease program/outcome, they should
be included under a respective disease grant. If these investments benefit more than one
disease program/outcome, such investments can be included in cross-cutting HCSS funding
requests.
13

At the planning/management level, HCSS investments can improve the organization,
management, capacity, establishment and funding of discrete parts (institutions or subsystems)
of systems, which are required for effective functioning of efforts to improve health.
Investments in this area will produce changes in the organization, capacity, management,
administration, policies and regulations in health and community systems

At the inter-sectoral level, HCSS investments may address weaknesses in the State functions
that adversely affect multiple sectors, including health, and consequently interfere with
effective delivery of disease control programs. Examples include public financial
management, civil service regulations, decentralization arrangements in federal states,
governance of civil society and community organizations, and coordination of the actions of
different sectors. These investments may also include support to inter-sectoral partnerships to
address human rights (e.g. through initiatives with lawmakers, human rights commissions, the
court system, prisons, police, etc.).
Funding requests for cross-cutting HCSS are expected to be mostly focused on
strengthening the systems performance at the planning/management level. Investments at
the operational level will be supported if the applications provide sufficient rationale
indicating that no other sources are available for uninterrupted function of the components
in question. As a general guidance, only a small portion of HCSS funding is likely to be
allocated for addressing the inter-sectoral level, as addressing most of these bottlenecks
goes beyond the Global Fund’s mandate.
Table 2 describes different types of system weaknesses and the ways in which they can be
addressed by Global Fund funding.
14
Types of system weaknesses
Illustrative Areas
Operational level:
 Occur at the national, sub-national,
facility and organizational levels;
 Require scaling-up of resources and
provision of other inputs to support
uninterrupted operation of systems.


Planning/management level:
 Occur at the national and subnational levels, mostly within the
mandate and capacity of the MoH,
community based organizations,
networks, and other system
stakeholders;
 Require policy and strategy
changes, institutional and structural
interventions, convening and
capacity building.
 Lack of reliable information on
scope and performance of
community systems









Inter-sectoral level:
 Are external to health systems but
may relate directly to concerns of
community organizations;
 MoH, health and community actors
have only a limited mandate and
capacity to intervene/address
intersectoral weaknesses.



Illustrative Impact of System
Weaknesses
Service delivery;
Health and community
workers;
Upkeep of infrastructure;
M&E


Procurement and supply
chain management;
Health information
system;
Health sector governance;
Governance and capacity
of community
organizations, and
networks of people living
with the diseases;
Human resources
Increasing equity by
expanding services to
underserved areas
Adequate planning of
community sector action
Public financial
management;
Decentralized public
governance systems;
Regulations relating to
establishment and
functioning of nongovernment and
community based







Disrupting service provision;
Reduces treatment access and
adherence;
Disrupting system management
functions.
Affecting health outcomes across
more than one disease programs;
Weakening enabling factors,
which normally enhance
effectiveness and efficiency of
the system (e.g. equity,
sustainability, transparency,
accountability, participation of
affected communities…)
Weakening regulatory,
management functions.
Duplication of efforts and
inefficiencies.
Impacts are systemic: they
change the way the State
regulates and administers the
health and community systems
and actors;
Impact is not exclusively limited
to the health and community
systems (i.e. other sectors such as
- education, water and sanitation,
Illustrative Interventions
to Address Weaknesses

GF funding
Provision of inputs (e.g.
HRH salaries, medical
supplies, vehicles; funding
for day to day
operations…)
Support to more
comprehensive community
mobilization and involvement
 National and sub-national:
mostly on the way the
system and its discrete
components operate;
 Requires complex
interventions by
combining multiple
activities from various
building block domains.
 Information systems to
capture more
comprehensively the state
and gaps within
community responses
Often funded by disease grants,
but may also be funded by HCSS
if benefits go beyond a single
disease, with proper justification
of absence of other resources.
National and multi-country: to
be agreed and implemented in
partnership with central
government entities (i.e.
legislative bodies, parliament),
beyond the MoH and with
regulatory bodies, civil society
organizations, networks and
activists; particular attention to
be paid to intersectoral
Limited: Global Fund may
provide support for only those
activities, which yield justifiable
effects for health and community
system functions, which benefit
the delivery of HIV/AIDS,
tuberculosis and malaria
programs, with proper
justification of absence of other
resources.
Most of HCSS funding will be
used to address these system
weaknesses.
15





organizations
Human rights and gender related legislation and
regulations.
Criminal justice system
Education system
Prisons
Social protection systems
courts etc. may also be affected).
weaknesses affecting the
community sector that result
from non-conducive national
policies.
Table 2: Health and community systems weaknesses
16
4. Links between Global Fund investments in HIV/AIDS, tuberculosis and
malaria programs and cross-cutting HCSS
As described above, cross-cutting HCSS investments should aim to eliminate system weaknesses
which interfere with the effective implementation of HIV/AIDS, tuberculosis, malaria and other
programs and the effective functioning of health and community systems in general, rather than
focusing on specific system components in a fragmented manner. The scientific literature
highlights three fundamental interdependencies between health and community systems and
disease programs:
 Weaknesses in services and other interventions delivered by health and community
systems undermine the impact of disease control programs;
 Even when a disease program is successful, it is unlikely that its health impact will be
sustained if the systems through which disease-specific services are delivered are
dysfunctional;
 A specific disease control program will not strengthen health and community systems
without an explicit strategy to address systemic weaknesses.
Therefore, the returns on investments in disease program depend on the way health and
community systems functions are performed to effectively contribute to improving access to and
quality of services needed to address equitably the comprehensive health needs of a population
beyond one specific disease and with efficient use of available resources.
Table 3 below illustrates the interdependencies between health and community systems and a
disease-control program. It provides an illustration of how specific investments in HCSS can
complement disease-specific grants. The example in Table 3 highlights three conditions for a
successful cross-cutting HCSS funding request to the Global Fund:



The identification of the specific causes of poor system performance through an in-depth
health and community systems analysis;
A combination of HCSS interventions falling under the systems components listed in
Annex-A;
A clear explanation of how the HCSS interventions support efforts to fight HIV/AIDS,
tuberculosis and malaria as well as health outcomes more broadly.
The table also provides illustrative examples of how cross-cutting HCSS interventions may
address disease-specific and more complex cross-cutting system bottlenecks. These examples
illustrate reciprocal interdependence between investments in HCSS and in disease programs,
further emphasizing the importance of a coordinated approach to designing funding requests.
Health issues to be addressed
through disease control
programs.
Example: HIV/AIDS
Traditional
responses of
disease control
programs
HIV prevalence remains high
among the general population
of country X and only 35% of
the key populations at risk
receive effective coverage
(utilization and quality are
poor) with a comprehensive
range of counseling, testing,
and treatment services.








Behavior
change and
communicatio
n campaigns
Distribution of
commodities
Community
mobilization
and outreach
with key
populations
Mobile HIV
counseling
and testing
Free provision
of ART to
HIV+ patients
Home care,
adherence
support
Training of
service
providers
including
community
outreach
workers in
HIV care
Separate
PMTCT
Potential sideeffects of disease
control programs
on health and
community systems
(HCS)
Coverage issues:
 Increased
utilization of
HIV services at
the expense of
other services
Efficiency issues:
 Primary care
providers and
community
workers spend
more time
delivering
specialized HIV
services, leading
to inefficient use
of human
resources
 Multiplication of
parallel
information
systems
overburdening
staff and
resulting in
unreliable data
on HIV
 Duplication of
parallel supply
chain
management
HCS weaknesses
affecting the performance
of disease control
programs and the
sustainability of their
outcomes
Inter-sectoral level:
 Lack of joint planning
between the Ministry
of health, community
sector, and other
sectors (finance and
education)
 Competition among
programs
 Legal and social
environment creates
barriers to effective
programs and causes
vulnerability in certain
population groups
(lack of enabling
environment)
 Insufficient linkages
with other social
programs
Management/planning
level
Health system
weaknesses:
 Insufficient, unevenly
distributed and
demotivated service
providers
Possible cross-cutting
HCSS interventions
How cross-cutting HCSS
may benefit the disease
control programs funded
Service delivery
functions:
1. Develop publicprivate partnerships
(PPPs) to increase
coverage with
services provided by
public health
programs
2. Integrate services for
maximum efficiency,
based on evidence, in
particular integrating
PMTCT programs
with broader MNCH
and SRHR services
3. Strengthen
community services
to reach key
populations
Service delivery
 Integrated services
allow decreasing
missed opportunities
while being more
responsive to patients’
needs with PMTCT
programs meeting
women’s needs as well
as protecting children
 Community services
for key populations are
likely to be better
targeted to needs, and
more acceptable to
marginalized
populations
Workforce functions:
4. Establish
performance-based
incentives for
multiple services
based on population’s
effective coverage of
needs
5. Scale up workforce in
Workforce functions
 PBI systems will
include measures of
coverage and quality
for all conditions and
don’t have to be
established for/by each
program
 Pre-service and
continuous education
systems will decrease
the duplication of
trainings by disease
Health issues to be addressed
through disease control
programs.
Example: HIV/AIDS
Traditional
responses of
disease control
programs

database for
monitoring
and evaluation
Development
of guidelines
for continuum
of care to
HIV+ patients
Potential sideeffects of disease
control programs
on health and
community systems
(HCS)
systems
Quality issues:
 Providers have
less time to
deliver all
services
according to
standards,
resulting in
missed
opportunities for
the delivery of
comprehensive
services
 Complex and
multiple disease
program
planning
processes affect
the effective
governance of
the health
system
 Facilities and
community
organizations
overburdened by
multiple
reporting
requirements
HCS weaknesses
affecting the performance
of disease control
programs and the
sustainability of their
outcomes
 Providers poorly
trained to treat
marginalized groups
respectfully and to
address gender and
other inequalities
 Inconsistent and
unsustainable
financing systems with
a mix of fee-for service
and free diseasespecific services, and
sporadic, unpredictable
funding particularly for
community
organizations
 Fragmented services
make it difficult for
people to access all the
services they need.
 Services not targeted at
populations most in
need, or tailored to
their needs
 National health
strategies are distorted
towards a few diseases
and do not reflect the
burden of disease; also
focused on formal
Possible cross-cutting
HCSS interventions
community sector,
paying particular
attention to
marginalized
populations
6. Integrate program
training curriculum
into pre-service
training and establish
continuous education
system for health and
community workers
Procurement and supply
functions:
7. Integrate procurement
mechanisms for
consumable health
products and
medicine
8. Decentralize stock
management based on
needs, including to
the community level
Information functions:
9. Transform the health
information system
into a health and
community system
information system
How cross-cutting HCSS
may benefit the disease
control programs funded
control programs and
the burden on service
providers
Procurement and supply
functions:
 An effective and
unique procurement
system is more
efficient and benefits
all supplies and drugs
 Decentralized stock
management is more
likely to prevent stock
outs of all drugs by
addressing the real
needs for consumables
Information functions:
1. The health &
community
information system
will provide
information on
systems performance
and how it affects
disease programs
2. New routine health
information systems
will provide the
19
Health issues to be addressed
through disease control
programs.
Example: HIV/AIDS
Traditional
responses of
disease control
programs
Potential sideeffects of disease
control programs
on health and
community systems
(HCS)
Equity issues:
 Burn out and
attrition of the
workforce due
to excessive
workload for
HIV programs
 Creation of
HIV-related
stigma, leading
to greater
difficulties in
reaching most
affected groups
 Payment
exemptions for
some patients
only
HCS weaknesses
affecting the performance
of disease control
programs and the
sustainability of their
outcomes
health system with
insufficient attention
paid to community
systems
Community system
weaknesses:
 Community
organizations
constrained due to
limiting regulations on
registration and limited
acceptance by health
sector
 Insufficient planning of
support to the
strengthening of
community sector
organizations
 Funding to community
sector is insufficient,
sporadic and
unpredictable
 Limited quality of
community based
interventions, lack of
norms for effective and
ethical practice
 Lack of engagement of
community actors,
Possible cross-cutting
HCSS interventions
by adding HCSS
performance
indicators and
mechanisms for
collecting them
reliably and
consistently
10. Streamline program
indicators and
integrate them into
the routine health and
community
information systems
ensuring sex and agedisaggregated data is
collected
Community functions:
11. Develop demand side
incentives for
population groups to
increase service
utilization
12. Develop
accountability
mechanisms at the
community level
13. Support community
mobilization and
How cross-cutting HCSS
may benefit the disease
control programs funded
information necessary
to decision makers at
all levels to allocate
resources and
prioritize health issues,
in line with need.
Community functions
3. Community level
incentives eliminates
barriers to utilization
of services and
addresses health issues
self-identified by the
population
4. Communities will be
engaged in their health
and will contribute to
building a more
responsive health
system
5. More effective
community organizing
and advocacy on
health in general
Legal, policy and
regulatory functions:
6. The standard
development unit can
20
Health issues to be addressed
through disease control
programs.
Example: HIV/AIDS
Traditional
responses of
disease control
programs
Potential sideeffects of disease
control programs
on health and
community systems
(HCS)
HCS weaknesses
affecting the performance
of disease control
programs and the
sustainability of their
outcomes
especially key
populations, in
program planning,
service delivery and
monitoring;
 Stigma, discrimination,
beliefs and risky social
norms
 Lack of accountability
of service providers to
the communities;

Operational level
Health system
weaknesses
 Lack of basic supplies
 Poor upkeep of
infrastructure
 Insufficient supportive
supervision and inservice training
Community systems
weaknesses
 Lack of basic supplies
and infrastructure
 Insufficient supportive
supervision and in-
Possible cross-cutting
HCSS interventions
leadership
development to
enhance advocacy on
program barriers
Legal, policy and
regulatory functions:
14. Development and
adoption of quality
norms for all health
and community sector
services
15. Build capacity of
health and community
managers in quality
assurance/quality
improvement
16. Support advocacy
particularly from
community sector
organizations on
social/environmental/l
egal barriers affecting
the impact of
programs
17. Strengthen
community
engagement in local
and national decision
How cross-cutting HCSS
may benefit the disease
control programs funded
develop clinical
practice guidelines and
SOPS for all types of
services with inputs
from content –
knowledge experts
7. District managers and
community based
networks can set up
quality improvement
projects to ensure
quality of any service
20. Enhanced recognition
of role of community
systems in AIDS, TB
and malaria response,
with adequate planning
for community sector
action
Financing functions
8. An insurance scheme
will improve financial
access regardless of
health needs and
increase utilization of
services
9. PPPs will be consistent
across all services and
programs, contributing
21
Health issues to be addressed
through disease control
programs.
Example: HIV/AIDS
Traditional
responses of
disease control
programs
Potential sideeffects of disease
control programs
on health and
community systems
(HCS)
HCS weaknesses
affecting the performance
of disease control
programs and the
sustainability of their
outcomes
service training
Possible cross-cutting
HCSS interventions
How cross-cutting HCSS
may benefit the disease
control programs funded
making related to
health and specific
disease programs
to increase coverage
and continuum of care
10. Community sector
programming is
consistent and
continuous and is
therefore more
supportive of health
systems.
Financing functions:
18. Replace payment
exemptions for
specific diseases with
an insurance scheme
with pooling prepayments (including
tax-based and
community-based
insurance schemes
where appropriate)
19. Develop mechanisms
to ensure predictable,
adequate financing
for all aspects of
community action
Table 3: Complementarity between investments in disease control and HCSS
22
5. Important considerations for developing cross-cutting HCSS funding
requests
5.1. Entry points for health and community systems strengthening
HCSS funding requests should be based on a comprehensive analysis of system weaknesses and
bottlenecks, with a particular focus on those that directly affect responses to HIV/AIDS,
tuberculosis and malaria. In most countries, national health strategies are based on an analysis of
weaknesses and bottlenecks, and they articulate system strengthening needs. The Global Fund
encourages countries to use these strategies, where they exist, as a basis for the development of
HCSS funding requests. However, the Global Fund recognizes that national health systems
analyses and strategies generally focus on a narrowly defined health system, particularly on stateowned facilities, management, governance and regulatory frameworks. In most settings, the
Global Fund anticipates that additional analysis will be needed to identify the weaknesses and
gaps within community systems.
5.2. Addressing common needs across HIV/AIDS, tuberculosis and malaria programs
As noted above, cross-cutting HCSS funding requests should be based on system-related needs
that are relevant beyond a single disease program and that impact on the entire health and
community system. However, it is essential that they have an impact in strengthening HIV/AIDS,
tuberculosis and malaria programs. Applicants for cross-cutting HCSS funding are required to
conduct an analysis of systems strengthening needs for each disease and for health and
community systems in general in order to avoid addressing similar system issues through different
funding requests. This will reduce the risk of duplication and creation of parallel systems, and
will help ensure a more coordinated approach to health and community systems strengthening.
5.3. Diagnosing underlying causes of poor systems performance
In order to sustain the impact of cross-cutting HCSS investments, it is important to eliminate the
underlying causes of poor health and community systems performance, rather than addressing
only the visible symptoms. This requires a thorough analytical needs assessment, that identifies
not only gaps or weaknesses in systems, but also their underlying causes. For example, in order to
sustainably address the shortage of qualified health and community workers, it is not enough to
quantify the gap and invest in workforce production to fill the gap. It is also important to analyze
what causes the problem (e.g. poor capacity of training institutions, ineffective providers’
reimbursement mechanisms, lack of sustained, predictable funding for community based
organizations…) and to include interventions that address these underlying causes. Such
assessments are usually conducted as a basis for developing broader national health strategies;
therefore aligning HCSS funding requests to the priorities reflected in national strategies and
additional CSS analyses is critical.
5.4. Seeking synergies with health outcomes beyond HIV/AIDS, tuberculosis and malaria
Many cross-cutting HCSS investments will also strengthen national systems in ways that help
improve health outcomes in areas other than HIV/AIDS, tuberculosis and malaria. There are
likely to be particular synergies with sexual and reproductive health and rights (SRHR) and
maternal, neonatal and child health (MNCH) outcomes. Applicants for cross-cutting HCSS
funding are particularly encouraged to identify and develop interventions that will promote such
synergies. Additionally, the Global Fund’s cross-cutting HCSS investments must be supportive of
the “do no harm” principle, which aims at preventing that donor-funded programs deliver on their
goals at the expenses of other, less-resourced programs (e.g. by drawing the attention of qualified
health/community workers toward HIV/AIDS, tuberculosis and malaria programs and thereby
reducing the amount of time they can spend on other health issues. Finally, it is important to build
not only on programmatic synergies with other health programs (e.g. immunization programs
supported by GAVI), but also with other donor-supported programs within the HIV/AIDS,
tuberculosis and malaria domains (e.g. PEPFAR, PMI).
5.5. Preempting potential side-effects of cross-cutting HCSS interventions
A complex range of interactions exists between the various components of health and community
systems. Intervening in one component of the system, may have a knock-on effect on other
components and the overall system. For example revision of providers’ reimbursement
mechanisms may influence the quality, effectiveness and efficiency of service delivery, by either
motivating over-performance, and thus reducing efficiency, or motivating cost-saving, which may
affect quality and effectiveness. Funding requests should therefore assess the potential interactions
between different interventions. In certain cases, additional interventions should be proposed for
preventing potential side-effects. For example, when changing a specific mechanism for
providers’ reimbursement, it may also be worthwhile to propose measures for monitoring quality
of service provision, for example by enhancing clinical audits, which would be useful of avoiding
the risk of affecting quality of care in the new financial environment.
5.6. Applying evidence-based interventions and innovative approaches
Cross-cutting HCSS funding requests should justify the value for money and the expected impact
of proposed interventions by providing any available evidence relating to the effectiveness of the
interventions, and by explaining their relevance in the given country/system context. At the same
time, this does not preclude the inclusion of innovative approaches in cross-cutting HCSS funding
requests. Applicants may propose such interventions, as long as they are accompanied by
convincing rationales.
5.7. Integrating outcome and impact measurement in cross-cutting HCSS funding requests
Measuring return is an essential part of any investment. The Global Fund’s 2012-2016 strategy
calls for support to high-impact interventions for strengthening health and community systems
and as such it is necessary to assess the outcomes and impacts of these investments. However,
because of the long causal linkage between HCSS interventions and health outcomes, measuring
the impact of cross-cutting HCSS investments in terms of disease prevalence and incidence,
mortality and morbidity is unrealistic. Where there is long enough timespan between the baseline
and control evaluations, cross-cutting HCSS funding requests should explain how they will
undertake assessments of system-wide impacts of HCSS investments. In addition, HCSS
outcomes may be measured by assessing how the effects of specific identified weaknesses, gaps
or bottlenecks have been reduced as a result of HCSS investments, or, by assessing how the
performance of a specific component (or a function) of the system improves. Where possible,
HCSS outcome/impact measurement should be an integral part of a country’s national health
information systems, in order to avoid the necessity of measuring additional indicators. However,
given that community systems performance is seldom if ever captured by national health sector
information systems, additional methods for evaluating the outcome and impact of investments in
community systems strengthening should also be developed.
6. Integrating Gender, Human Rights, RMNCH and Other Cross-cutting
Issues in HCSS
Human rights violations and gender inequalities are a root cause of vulnerability to AIDS,
tuberculosis and malaria, and of the marginalization of certain groups from AIDS, tuberculosis
and malaria programs. Upholding international human rights standards is essential for the overall
success of national responses to three diseases. The Global Fund is committed to ensuring that it
24
does not support programs that infringe international human rights standards, to increasing
investments in programs that address human rights-related barriers to access to services, and to
integrating human rights considerations throughout the grant lifecycle. This commitment is
equally applicable to both disease and cross-cutting HCSS investments. All Global Fund
supported programs should recognize and address specific needs of women, girls, men who have
sex with men, people who inject drugs, sex workers and transgender people, and other groups that
are marginalized or highly affected by HIV/AIDS, tuberculosis and malaria.
To promote gender equality and human rights in the response to the three diseases, the Global
Fund may support programs that address stigma and discrimination and increase access to justice
in each disease-specific program as enablers/synergies. Similarly, where relevant, cross-cutting
HCSS grants should include human rights-based and gender sensitive/responsive programming,
based on assessments of gender and human rights conditions, and developed with the meaningful
participation of underserved and key populations at higher risk, including vulnerable or
marginalized communities. Advocacy for legal reforms that enable provision of equitable and
quality health services should be based on evidence, promote non-discrimination, and represent
progress towards meeting states’ obligations under international human rights standards.
When preparing cross-cutting HCSS funding requests, countries should explore where
development synergies may already exist that aim to promote gender equality, to strengthen rule
of law, accountability, and human rights standards. For example, in a country that already has
programs in existence that are working to create new policies addressing discrimination in health
systems, cross-cutting HCSS funding may be used to add HIV/AIDS, tuberculosis and malariarelated components and to ensure participation of affected communities to those programs.
In high-burden countries where women and children account for a significant portion of the
affected population for the three diseases, integration of RMNCH services offers opportunities for
improvement of disease-specific outcomes. Beneficiaries seeking HIV/AIDS, tuberculosis, and
malaria services and those seeking RMNCH services have common needs. Integrated services can
save lives by ensuring women and children receive comprehensive care in one location and that
opportunities to address co-infections and prevent mother-to-child transmission are not missed.
Examples of cross-cutting RMNCH interventions that contribute to HCSS and may be supported
by the Global Fund under cross-cutting HCSS funding requests include:




Developing, implementing and monitoring health legislation, policies, and regulations
Integrated training (pre- and in-service) to inform health providers and enable them to
address RMNCH, HIV, TB and malaria interventions together and to meet the needs of
key vulnerable populations such as women, children and adolescents
Demand creation through community mobilization of women, men, and vulnerable
populations such as adolescents
Community-based service delivery, referral systems and community peer support to
increase uptake and follow-up
Not all gender or human rights programming is suitable for cross-cutting HCSS investment. To be
eligible, programs must specifically contribute to the effective implementation of disease
programs and must address country obligations under international human rights standards.
General programs aimed at promoting rule of law and promoting the broad concept of gender
equality, are not eligible for cross-cutting HCSS support.
25
Annex A: Indicative scope of Global Fund’s investments in HCSS
The table below provides an indicative scope of HCSS interventions, which countries may
consider for designing cross-cutting HCSS funding requests. The indicative scope does not imply
a prescriptive approach to strengthening health and community systems. While it highlights the
prioritization of the Global Fund’s resources for HCSS investments, it is also meant to provide
enough flexibility for designing activities based on country-specific needs. For example, under
intervention 1.2, Country-A may request funding for developing referral system regulations,
Country-B for installing a hospital accounting system, and country-C for improving hospital
waste management system and Country-D for building the capacity of women’s organizations to
engage in health assessment, planning and monitoring processes. Similarly, under intervention
1.3, illustrative examples of proposed activities may include - revision of clinical guidelines, or
standardizing terms of reference for community health volunteers. In many cases addressing
specific system bottlenecks or weaknesses will require a complex approach by combining
interventions classified under more than one components of health and community systems. For
example, addressing poor technical capacity and shortage of qualified health and community
workers may be addressed by scaling-up training programs, but in order to increase the
effectiveness of the intervention and to sustain its outcome, it can be combined with upstream
interventions such as for example developing policies for equitable allocation of qualified
workforce to hard-to-reach areas, and developing financial mechanisms for workers’ retention
incentives. Such an integrated approach to designing complex interventions is encouraged, but
proper justification should be provided to explain why the proposed combination was considered
effective for addressing the identified system bottleneck, weakness or gap.
26
System components
Illustrative List of Interventions
1.Scale-up and improve
accessibility and quality
of service delivery, including
community level services
1.1. Scaling-up or improving service infrastructure (except large-scale construction projects)
1.2. Improving service organization & facility/community based organization management
1.3. Improving quality of services and interventions
1.4 Development and implementation of referral and support networks and systems in particular between health and community
system entities;
1.5. Skills building for facility and community-level service delivery, advocacy & leadership in integrated services such as
TB/HIV, SRHR, comprehensive PMTCT, maternal and child health and protection;
1.6. Improving community-level service availability, use and quality, and equitable reach
1.7 Advocacy on legal and policy frameworks e.g. decriminalization of behaviors or marginalized groups; development and
enforcement of child protection policies;
2. Produce, distribute and
retain skilled health and
community workforce
2.1. Providing or improving pre-service and in-service training to all service providers, health and community workers
2.2. Scaling-up health and community workforce
2.3. Supporting health and community workforce retention
2.4 Technical capacity building for health support roles at the community level
2.5 Capacity and skills building to enable health workers and community level personnel to work effectively, safely and ethically;
3. Strengthen
procurement & supply chain
management system
3.1. Scaling-up or upgrading PSM infrastructure
3.2. Improving operationalization of PSM system (and strengthen linkages with other health services such as SRHR and RMNCH)
3.3 Supporting community level monitoring of PSM (e.g. early warning systems of stock outs)
4. Strengthen
Health and community
information systems
4.1. Scaling-up or improving routine M&E including sex and age disaggregation of coverage and reach data
4.2. Improving community level M&E and evidence-building
4.3. Scaling-up or improving analytical and research capacity
4.4. Scaling-up or improving epidemiologic and disease surveillance systems
4.5 Contributing to improved “knowledge management” by supporting sharing of information, tools, good practices etc. within
communities.
4.6 Building systems to provide reliable information on the role and functions of community systems, needs assessments, and gap
analyses
5. Empower community and
other local actors
5.1. Supporting community-led advocacy, communication and social mobilization and communication strategies
5.2. Strengthening and scaling-up resources and capacity of community groups and networks
5.3 Mobilization of communities and key affected populations to engage actively with decision makers, and represent community
issues in major discussion forums relating to health and rights, especially for allocating resources and for reflecting the health and
rights issues in the National Strategic Plan.
5.4 Mapping of challenges, barriers and rights violations experienced by key affected populations and developing policy analysis,
recommendations and strategies to improve the environment;
5.5 Development of communication, participation and leadership skills for working with communities and individuals and
implementing local advocacy initiatives;
5.6 Developing strategies and plans for community systems strengthening
6. Create enabling legal,
policy and regulatory
environments
6.1 Developing, ratifying and executing evidence-based, non-discriminatory laws, policies, regulations, coordination and
supervision mechanisms; advocacy aimed at promoting appropriate legal and policy reform
6.2 Building capacity to implement laws, policies and regulations; supporting litigation
6.3 Developing and supporting independent mechanisms to supervise, monitor and report on implementation of laws and policies
6.4 Advocacy for better governance on decision-making, policy-making and use of resources by public institutions
6.5 Ensure meaningful participation of community actors in national consultative forums, including policy, planning and other
decision making bodies;
6.6 Develop national partnership platforms and national level advocacy coordination mechanisms;
6.7 Monitoring and documentation of community and government interventions
6.8. Improve strategic and operational planning, management, accountability and leadership, including for community systems
6.9. Build community linkages, collaboration and coordination
7. Ensure adequate financing
of the health and community
system
7.1 Improving revenue collection, pooling and purchasing for ensuring financial sustainability of service delivery
7.2 Improving equity of healthcare and community level financing
7.3. Improving public financial management
7.4 Assessing the level of funding required for community-level service delivery
7.5 Development and management of funding schemes for communities, including core support such as social transfers for
vulnerable people, social welfare services, child protection and health-related income generating activities;
7.6 Development and management of schemes for remunerating community outreach workers and volunteers or providing other
incentives and income-generation support.
7.7 Physical infrastructure development, including obtaining and retaining office space and equipment, improving communications
technology, provision and maintenance of transport for community based organizations;
Table 4: Indicative scope and illustrative examples of the Global Fund’s investments in HCSS
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