Community Systems Strengthening ICW & Women4GF StatementStatements

tag AIDS,HIV,TB,Women

Released date: 26-Aug-2015

Strengthening Community Responses

Community Systems Strengthening (CSS) in the Global Fund Strategy 2017 – 2021

As defined by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Community Systems Strengthening (CSS) Framework was created and designed to support the development of functional community organisations and networks, and build the capacity of existing community sector organisations to monitor health and human rights services and programs; to advocate for change and accountability; to strengthen community organising and mobilisation; and to deliver services effectively.

Current Context of HIV, Tuberculosis and Malaria

Despite unprecedented progress in the global HIV response – economic inequality, social marginalisation and other structural factors continue to fuel the HIV epidemic,1 including stigma and discrimination, gender inequality, gender-based violence, and punitive laws against key populations. Globally, 70% of people living in poverty are from middle-income countries. HIV/AIDS and Tuberculosis (TB) remains one of the top 10 leading causes of death for women in Lower Middle Income and Upper Middle Income countries. Domestic investments in health in low and middle-income countries vary widely and are often inadequate to meet the needs of communities, especially if they are marginalised, resulting in ostracised and vulnerable communities being left behind. This is exacerbated in environments where key communities are broadly discriminated against and criminalised.

It is estimated that out of the 35 million people living with HIV globally with 16 million women.2 Meanwhile, TB is the leading cause of death among women. Annually, about 700 000 women die of TB, and over three million contract the disease, accounting for about 17 million Disability Adjusted Life Years (DALY). Their children and families are impacted given that TB affects women mainly in their most economically active and reproductive years. The mortality, incidence, and DALY indicators do not reflect this hidden burden and social impact.3 Furthermore, pregnant women and their babies are especially at risk from malaria, especially during pregnancy, which can lead to stillbirth, low birth weight and other complications.4

An Urgent Need

There is an urgent need to ensure resources are invested strategically to support interventions and populations that yield the highest impact and progress on HIV, TB and malaria. Over the last three decades, community-based responses have been a prominent feature of the health response. The investments towards the engagement and participation of communities – shaping and driving the response has led to many gains – including leveraging ‘lived experience’ and an understanding of what does/does not work for women in communities. Communities of people living with and/or affected by HIV, TB and malaria have delivered effective services that reach marginalised and hidden populations. These gains cannot be lost and should be accelerated for great impact, for increased investments need to be made in programmes and interventions that have a link to effectiveness of communities responses, especially amongst groups and communities of women and girls.

Community systems, for example, support groups of women living with HIV, are essential for peer-based programmes around psychosocial support, treatment adherence, changing social norms and stigma-reduction, creating awareness of programs and schemes, and for creating demand. Investment in effective linkages and referral systems between community and health systems helps ensure that no one is left behind. Community-based approaches connect people to services; are flexible and responsive to community needs and address important barriers in community access to services and support what happens beyond clinic walls. Community organisations support the continuum of care – putting people in touch with health care systems, from diagnosis, through treatment and ongoing care and support. Importantly, community responses disseminate risk reduction information in easily understood language and empower people to be more health conscious.

Women, as the main agents of primary health care, play an essential role in maintaining family and community health. We are most aware of community sickness and suffering because of our social role as nurturers and caretakers of the young, old, sick and disabled, and we exert an important influence on health habits in the family. It is often recognised that primary health care has to respond to the needs of people, and that women have the most awareness of these needs, yet our opinion is undervalued and inadequately solicited when health care programs are formulated.

CSS Investments by the Global Fund in Round 10

CSS investments have remained relatively low. In Round 10, when applicants for the first time could refer to the CSS Framework to include support for CSS in their disease proposals or cross-cutting HSS funding requests, 65 of the 150 diseases proposals (43%) as well as six of the 28 cross‐cutting HSS requests (21%) reviewed by the TRP included CSS interventions for a total funding request of US$251 million for Phase 1 and US$623 million over the proposal term. Funding requests for CSS interventions represented only 6% of the overall 2-year and 5% of the overall 5‐year funding requested in Round 10.

There has been no gender analysis of Global Fund funding in women and girls beyond PMTCT to date, and none for CSS funding from the Global Fund on gender.

Moving Forward

In order for health responses to benefit from our knowledge, health programs must encourage participation of people at the grass-roots, especially women and women’s and girls’ rights organisations, in the decisions affecting individual and community health.5 To ensure this inclusion, it is essential that government health systems are linked to strong community networks of women. To achieve impact, resources and deliberate efforts around meaningful involvement of women and girls must be made available, including resources for monitoring and accountability, advocacy, social mobilisation, community linkages, collaboration, service delivery, institutional capacity building, planning and leadership development.

The UNAIDS Strategic Investment Framework identifies community mobilisation as a critical enabler for programmatic success in the AIDS response. In addition, the Global Fund’s Community Systems Strengthening (CSS) Framework provides the blueprint for effective and sustainable investments in communities. The continued support for CSS related activities from funding agencies is essential to ensure effective, quality and wide reaching HIV, TB and malaria responses. These activities have to be enabled at the national level with community response articulated within national strategies and with the full support of technical agencies during design and implementation for them to be effective, so that health systems and community systems complement each other.

The Global Fund CSS Framework articulates the need for comprehensive support to community organisations including core funding, organisational development, and direct funding for program implementation. The role that communities play in terms of direct service provision is undisputed, however communities need to be well resourced to feed into and influence decision making and policy processes and deliver the services they are already providing on shoe string budgets. Communities especially networks of women living with and affected by HIV, TB and malaria are best placed to advice on bottlenecks, implementation challenges and to provide concrete suggestions where improvements are necessary. It is for this reason that the GES Action Plan notes in objective 2.2 the need to Strengthen civil society partners, including women’s organisations and organisations of women living with or directly affected by the three diseases, to effectively integrate gender into Global Fund grants. The CSS Framework needs to be implemented alongside the Gender Equality Strategy and the Sexual Orientation and Gender Identities Strategy, as CSS is a tool through which women, especially those from key populations can be strengthened to maximise their contribution to HIV, TB and malaria.6

Recommendations to the Global Fund in the 2017 – 2021 Strategy

We call on the Global Fund to ensure that our concerns are addressed in the development of the Global Fund Strategy 2017 – 2021:

  • The Global Fund Secretariat together with technical partners, must support countries in enabling active participation of networks of women living with HIV, and directly affected by TB and malaria in all stages of programme development, implementation and evaluation to achieve effective implementation of interventions. With a third of Global Fund grants being implemented by civil society organisations (CSOs), the Global Fund must work together with governments and partners to ensure that there are skilled and experienced networks of women living with HIV as implementers to engage with within the Global Fund structures, as CSOs currently implementing are typically international NGOs and often lack the experience/expertise/motivation to work with women and girls.
  • The Global Fund Board must ensure that its new strategy specifically addresses the importance of investing in community responses – specifically advocacy and monitoring so that resilient and sustainable systems for gender equality can be achieved.
  • Clear and achievable Key Performance Indicators (KPIs) must measure the successes of Global Fund investments in community responses, including in CSS, and more specifically the impacts of CSS need to be captured. At a minimum, this needs to also be addressed through the planning of national programmes with gender and age-disaggregated data, so that investments towards women and girls for CSS can be captured accurately.
  • The Global Fund with governments must support the implementation of all components of the Investment Framework for HIV programming as an evidence-based model to guide prioritisation of efforts. The Investment Framework is also relevant for TB and malaria to guide prioritisation of efforts. Community mobilisation is a critical component of the Framework that will enable major efficiency gains and ensure that interventions are grounded in reality and based on the principles of universal human rights. Ensuring gender equality and human rights are key components of the Investment Framework.
  • The Global Fund must strengthen systems of communities, including networks of key affected women by investing in institutional and structural strengthening of their networks through funding and providing technical support for networks and organisations beyond concept note development. This includes the investment in women and girl’s leadership to guarantee the sustainability of community organisations and groups working for key affected communities through core funding support. This will sustain advocacy and participation in designing, implementing, monitoring and evaluating programmes and policies that directly affect them while ensuring continuous efforts and investments in middle income countries. Programmes that work with key affected populations – including female sex workers, drug users, prisoners, and transgender people also must consider their partners, and plan interventions according to epidemiological and behavioural data in a rights-based environment.
  • Support capacity building of Country Coordinating Mechanisms (CCMs)/key government institutions and other HIV/malaria and TB in-country stakeholders on gender equality and CSS. To foster an enabling environment for CSS and gender programming and budgeting in Global Fund grants (and community and women and girls participation in in-country GF processes).

Recommendations to Governments to Scale Up and Community Responses and CSS

  • Governments must provide adequate space and opportunity for networks of women’s CSOs to participate in policy-making processes, not only during the country dialogue process, but also in decision-making processes on the CCMs as well during processes to develop the National Strategy Plans (NSPs).
  • Community Responses and CSS (which includes core funding and organisational development) must be understood and broadly endorsed by governments, so that it can be actualised by the Global Fund to support women’s networks. This is not only to provide services but also to monitor, document and analyse health services performance as a basis for accountability, advocacy and policy undertakings.
  • Note and meaningfully meet GF requirements of seat quotas for CS and communities and women in CCMs.
  • Something on domestic investments to CSS and gender equality/women and girls?
  • Strengthen all laws and policies to protect the human rights of key affected women and girls, including women and girls living with HIV. Ensure an enabling environment by decriminalising all sex work, drug use, same-sex behaviour and relationships and transmission of HIV.
  • Remove barriers to women and girl’s access to non-judgmental gender sensitive health and legal services, and address stigma and discrimination in health care settings for key affected women and girls including ending forced sterilisation, forced abortion and compulsory HIV testing among women and girls.

Recommendations to Technical Partners in Countries

  • Technical Partners especially UNAIDS with its cosponsors must actively work with networks of women living and affected by the three diseases in country, to encourage, enable, empower, and facilitate their involvement in country-level processes from the development of NSPs, to the continuous country dialogue that should be taking place after grant-signing and during implementation.
  • During the country dialogue process, and development of the concept note, the role of technical partners need to be encouraged to integrate more effective gender-related and gender-transformative activities based on gap analysis and evidence, where gender equity needs to be considered in all relevant service delivery areas.


The International Community of Women Living with HIV/AIDS (ICW) is the voice of, and represents women living with HIV, in all our diversity. ICW works in 120 countries and through 10 regional networks.7 ICW is committed to addressing the multiple oppressions experienced by women living with HIV globally. For more information contact ICW Global Director – Ms Rebecca Matheson at

Women4GlobalFund (W4GF) is a movement that brings together women’s rights advocates and organisations – especially women living with HIV, and directly affected by TB and malaria – to advance gender equality through the Global Fund. W4GF mobilises women in all their diversity to ensure that the world’s most important financing mechanism for HIV, TB and malaria supports programmes that meet the rights and needs of women and girls to improve and deliver equitable health outcomes. For more information, please visit our website or contact at or

  6. CSS Framework information Note
  7. Asia Pacific, Caribbean, Central Africa, East Africa, Europe and Central Asia, Latin America, the Middle East and North Africa (MENA), North America, Southern Africa, and West Africa

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