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CSS walked so CLM could run: examining the community led monitoring structure for improved HIV service delivery

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BACKGROUND: Over the past decade, the expansion of HIV prevention, testing, and treatment has halved new infections. Progress has been uneven, however. For instance, incidence is rising among men and men who have sex with men. The failure to disaggregate data has masked the service delivery challenges that gave rise to health disparities like this. Community-based organizations (CBOs) have been instrumental in highlighting these challenges.
Community Systems Strengthening (CSS), and Community Led Monitoring (CLM) are two CBO driven approaches to bridge the data gap and identify service delivery solutions.The CSS Frameworkwas developed by the Global Fund in 2010. The first CLM project was established and in 2020, PEPFAR mandated that all its programs implement a CLM project.
Given the lack of literature comparing these frameworks, we sought to identify key differences between the two and describe the added value of CLM.
METHODS: We performed a literature review and informational interviews to delineate activities of CSS projects conducted under the Global Fund Health Systems Strengthening (HSS) grant. We then composed case-studies of three CLM Projects in Uganda, South Africa, and Haiti to examine operational country-specific CLM projects. Using these materials, we qualitatively analyzed CSS and CLM programs, paying attention to structure and activities.
RESULTS: In the context of HSS, a framework for clarifying essential functions within a formal health system, the major contribution of CSS was to highlight the role of CBOs in improving services. Efforts under CSS were uncoordinated and sporadic with an emphasis of capacity building' yet, lacked dedicated funding. By contrast, CLM is a routinized, structured approach to the monitoring and improvement of services. In all three case-study countries, affected communities led the coordination and implementation of CLM. While it is too early to assess sustainability, multiple donors have committed to continued support of CLM projects.
CONCLUSIONS: CSS was essential to building community networks and enhancing their involvement in health care delivery. CLM emerged from CSS but has a strong focus on data-informed advocacy to improve donor and government accountability through a community-owned mechanism. CLM is an important tool to end inequalities around access and treatment.