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“CLM as part of national monitoring: are we ready?”

Donald Denis Tobaiwa

Executive Director

Jointed Hands Welfare Organisation

5 December 2023

Outline

What Is CLM

COMMUNITY-LED MONITORING (CLM) uses the power of communities to transform information on health systems into life-saving advocacy campaigns. It rapidly generates data on Health services and empowers communities to use their findings to identify and advocate for solutions that break down barriers to human rights, better health and better quality of life

What is CLM -WHO IS THE COMMUNITY�

• Broadly, communities are formed by people who are connected to one another in distinct and varied ways.
• Communities are diverse and dynamic, and one person may be part of more than one community
• People who access health systems with an aim to improve their health.
• People who are particularly affected by a health problem.
• People who share specific characteristics or vulnerabilities due to their gender, identity, geography, behavior, ethnicity, religion, culture or age.
• Groups that represent these people.

What is and what is not CLM

THE CLM CYCLE

CLM data is collected from the community and at service delivery points as follows;

• Getting the views of Service Users
• Getting views from the Health Care Providers.
• Getting the views of special groups (KVPs) accessing services at the health facility
• Getting the views of groups of people who have shared experiences
• Observing service delivery at the health facility
• Collecting and documenting stories of service recipients

HOW CLM DATA IS COLLECTED

Zimbabwe Case Study- Are we ready?

• Zimbabwe piloted the CLM from as way back as 2010, with different models including CTO, Community Monitoring and the PEPFAR Site Monitoring which began the systematic structuring of CLM in 2014 through the Advocacy Core Team (ACT), being piloted in 5 Districts , the 2^nd phase was in 2016 and scale up started in 2018.
• Zimbabwe has multiple donor funded CLM models , not limited to but including, PEPFAR CLM (in PEPFAR Districts) With FY 2016 resources, PEPFAR supported CLM startup in five pilot districts initially through the Advocacy Core Team and this support expanded gradually to 32 Districts across the ten provinces of Zimbabwe. 
• The country is currently developing a National CLM strategy.

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Zimbabwe Case Study- Are we ready?

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Policy level and sector representative advocacy body , sits Quarterly, coordination , tools standardization , leading development of the National CLM strategy

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Zimbabwe

• Across all the CLMs in Zimbabwe the CLAW designed phased cyclical methodology is used.
• What only differs are the hosting platforms, mode of data collection and Geographic areas - with some overlapping eg One Impact.
• PEPFAR uses Comcare, Global Fund uses ODK , One Impact uses the Mobile Health Digital platform
• Works with the ICT department and issues for quick resolutions escalated via the interoperability functions

Data Collection & Use

• Data collection, primarily in health facilities and surrounding communities, is the first phase of the CLM cycle after project set-up.
• The focus of the monitoring is usually determined by the organization(s) implementing the project (in 69% of programs) and community members (62%), although a minority of respondents described donor and government leadership in designing data collection tools (26% and 23%, respectively).
• The most common topics monitored include accessibility and quality of services for key and vulnerable populations (90% of programs); stigma, discrimination, and staff attitudes (82%); availability of services in the community (79%); and availability of medicines and stock-outs/shortages (79%).
• In 55% of programs surveyed, data are collected by members of communities impacted by the three diseases using electronic tools such as District Health Information Software 2 (DHIS-2), CommCare, and OneImpact.
• While many programs report a small scope, with 26% monitoring in 25 or fewer facilities, a small minority of programs report monitoring in more than 400 facilities.

Data Collection to date

Data analysis and use

Data analysis and use

Data analysis and use

Data analysis and use

Data analysis and use

Data analysis and use

Challenges Impacting TB Testing

Challenges Impacting TB Treatment

Advocacy & Notable Wins to date-Strategic

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Advocacy and notable wins to date- Community

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CLM Experiences

• Increasing role of institutions in CLM in coordinating , guiding and supporting CLM which should delicately be balanced with “let the communities lead” approach.
• Need to constantly and systematically alert and motivate communities to recognize that despite institutional leadership, they remain key to CLM and as such they should lead.
• The contest, conflict, inclination and gravitation towards making CLM universal, national, systematic and homogenous tends to invariably undermine the community nature of CLM.
• Communities are diverse, across all fronts, gender, socially, etc.
• To this end, universalizing CLM undermines the community nature of CLM results, resulting in dilution , neglect and in some cases total disregard of community level interests in favour of nationally defined agenda.
• Investment in CLM is key. Community dynamics are real across a number of perspectives.
• A one size fits all approach to supporting CLM will affect the community centeredness of CLM.
• The wins tend to thin as issues assume subnational and national level nuances.
• This pattern of success points in some way to subnational and national level disconnect in available advocacy and engagement platforms and time sensitive alert mechanisms for CLM.

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CLM Financing

• CLM costs money: implementing organizations have to hire core staff, pay for office space and equipment, buy data collection tools like tablets and server hosting services, pay for travel expenses and salaries for data collectors and advocates, and publish reports and media products.
• In a survey conducted by CLAW ;
• The most commonly reported donors were the Global Fund, PEPFAR, and Stop TB Partnership with 97% of respondents reporting receiving funding from at least one donor, and 40% receiving funding from more than one donor
• Funding levels for CLM programs ranged widely, from those with budgets less than $10,000 per year (40% of which are HIV projects) to programs spending more than $1 million per year (primarily large TB monitoring projects). In general, programs averaged between $8,000 and $9,000 per site monitored.
• Nonetheless, nearly all programs reported not having enough funding to pay for all their planned activities, and 67% reported that funding is sometimes, often, or always delayed.

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• BEST PRACTICES

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61%

of programs received funding from the Global Fund

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88%

of programs report not having enough funding to reach their objectives

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67%

of programs report that funding is sometimes, often, or always delayed

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CLM Resources

• Community Evidence to Create Change led by the- Community-Led Accountability Working Group (CLAW Consortium)
• Best Practices for community-led monitoring (CLAW)
• Community-led Monitoring – Best Practices for Strengthening the Model
• Conflict of Interest in Community-led Monitoring programs (CLAW)
• Data for Action - Developing a Multi-Country CLM Dashboard for Visualization, Reporting, and Program Management
• Lifting Up Key Populations Voices and Increasing Quality of HIV services in Malawi: Using Community Led Monitoring to Strengthen Services for Key Populations and People Living with HIV
• CSS Walked So CLM Could Run: Examining the Community Led Monitoring Structure for Improved HIV Service Delivery
• Lessons Learned in Community-Led Monitoring: Early Evidence From Global Study Of The Implementation Landscape
• Barriers Impeding Care for People Living with HIV: Early Findings From Community- Led Monitoring in Haiti
• Evaluation of Ritshidze Community-Led Monitoring Programme in South Africa
• Human rights violations against key populations in South Africa Public health facilities: Findings from the Ritshidze Community-led Monitoring Programme
• Establishing community-led monitoring of HIV services Principles and Process- UNAIDS 2021
• UNAIDS 2021; GLOBAL AIDS STRATEGY 2021–2026 END INEQUALITIES. END AIDS: https://www.unaids.org/sites/default/files/media_asset/global-AIDS-strategy-2021-2026_en.pdf

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• led by the
• Community-Led Accountability Working Group (CLAW Consortium)

Acknowledgements