TB Partnerships: Whole is greater than the sum of its parts

A report released online earlier this week states that effective partnerships can improve tuberculosis responses globally. The summary report, titled, "Whole Is Greater Than The Sum Of Its Parts", was also distributed at the 42nd Union World Conference on Lung Health in Lille, France (online at: http://www.citizen-news.org/2011/10/tb-partnerships-whole-is-greater-thanhtml). This report is the summary of the online consultation that was facilitated by CNS: www.citizen-news.org – a partner of the Stop TB Partnership - using social media platforms and also the Stop-TB eForum that was established by the Health and Development Networks (HDN) in early 2001, and currently is supported by the Stop TB Partnership, the International Union Against Tuberculosis and Lung Disease (The Union) and the International HIV/AIDS Alliance, and managed by CNS. The online consultation was held during October 2011.

The guiding question was: What are the different types of groups, people, organizations or entities you have partnered with to fill a gap in TB prevention, care and/or control?

OVER HUNDRED COMMENTARIES FROM 24 COUNTRIES came in through a diverse range of channels including the global Stop-TB eForum, blog, twitter, Facebook, and comments sent by email.

The participants of the online consultation came from the following countries: Afghanistan, Bangladesh, Brunei Darussalam, Cambodia, Ghana, India, Indonesia, Kenya, Mexico, Myanmar, Nepal, Nigeria, Pakistan, Saudi Arabia, Sri Lanka, Switzerland, Tanzania, Thailand, Uganda, United Arab Emirates, United States of America, Viet Nam, Zambia, and Zimbabwe.

ACSM STRATEGIES
A strong element of some partnerships has been the advocacy, communication and social mobilization (ACSM) strategies. For example in Mexico, the national TB programme (NTP) provided its technical expertise and infrastructure and PCI through its SOLUCION TB Programme provided the knowhow of working with affected and vulnerable communities.

PERSON-CENTRE MODEL FOSTERING COMMUNITY EMPOWERMENT
An important innovation of a partnership consisted of the appropriation of a person-centered model of service delivery and mechanisms that foster community empowerment and work to reduce stigma and discrimination. The partnership addressed healthcare needs for TB, HIV/AIDS and diabetes.

ENGAGING MOST-AT-RISK-POPULATIONS
Engaging most-at-risk-populations (MARP) as equal partners with dignity is crucial to make programmes work optimally. These MARPs include: Injecting drug users (IDU), poor people, people living with HIV (PLHIV) among others.

INFORMAL PARTNERSHIPS WORKED
A participant from Nigeria said: “The structured partnership mechanism set up by Stop TB Partnership (Nigeria Stop TB Partnership has not worked due to so many reasons including interim National Committee's inability to function. However, at informal level partnership for TB control and care has worked and is an effective tool for TB control and care. Through our organisation advocacy efforts, we have been able to form informal partnership with community leaders and community members, thus involving and selecting community volunteers for TB case finding. Also informal partnership with primary health centres in the community has helped to educate TB patients on drug adherence and other issues.”

IMPROVING COUNTRY-LEVEL PARTNERSHIPS AND ALIGNMENT
Open, simple and practical communication solutions are also a key in making partnerships work at all levels.

REAL COLLABORATION AND COORDINATION
Partnerships require real collaboration and coordination, not just meetings. Many participants described weaknesses not so much in the model itself, but in how it is being implemented. The issue of community voices being present in various partnerships – but not necessarily heard – was raised repeatedly. They need to be involved at all levels – planning, budgeting, implementation, and monitoring and evaluation phases.

PARTNERSHIPS SHOULD ENSURE LOUDER VOICES DON’T DOMINATE
Country-level partnerships should make sure that louder voices don't dominate- and - they are truly driven by the communities even if governments, big NGOs and donors are a part of it.

COMMON AGENDA NOT CONFINED BY ORGANISATIONAL MANDATES
Partnerships work only when members agree on a common agenda rising above and beyond their organisational agendas at times. If we limit ourselves to our organisational mandates only, then partnerships are likely to suffer.

NEED TO ENGAGE NON-TRADITIONAL STAKEHOLDERS
Participants also highlighted the need to engage non-traditional stakeholders such as other Ministries in addition to Ministries of Health and other non-governmental organisations other than those working on TB directly (for example those working on diabetes, HIV, poverty, nutrition among other issues).

TRUST IN COMPETENCE OF CIVIL SOCIETY
A participant said: “We also have to stop thinking that civil society cannot do the work properly.” People who are dealing with TB are also equal partners in finding solutions that work. In order to optimise the reach and impact of TB programmes, affected communities need to be involved meaningfully at all levels. Their expertise in ‘reaching the unreached’ among others must be recognized and duly respected. Another participant said: “Real action if any has, and will, come at local level. That is where a partnership can make a real difference.” Another participant said: "One way to make sure that the partnerships are community driven is to ensure that these are not run by governments - and – civil society gets direct funding or support. We need to trust the competence of civil society - and - its ability to learn, organize and innovate when given a chance. Give it a chance."

PARTNERSHIP FUNDING – A DOUBLE EDGED SWORD
Managing partnership funding – both a challenge and an opportunity. Said a participant: “Even without money, voluntary partnerships of civil society or diverse stakeholders are never easy to manage. With money things can become more difficult if we are not careful. It is a double edge sword.”

IMPROVED MONITORING AND EVALUATION
Participants highlighted the need for improved and collectively developed monitoring and evaluation systems so that medium and long-term objectives, indicators and targets align with national systems.

PARTICIPATION AND REPRESENTATION
A participant said: “All partners must realize (especially those more in power) that by increasing participation and representation they will strengthen the partnership as a whole and achieve much more than they will ever individually or in smaller groups.” Representation by different members should be consultative with the constituencies they respectively represent.

IMPROVING COORDINATION AND INCLUSION
The partnership needs to be coordinated well and in such a way so as to stimulate more inclusion of partners in strategies, decision making and other areas such as advocacy planning at all levels. A participant said: “Smaller partners are not there just to implement what the big partners decide.”

TRANSPARENCY
A participant said: “Transparency within the partnership is very important indeed especially when it comes to financial matters.”

GOVERNANCE AND MANAGEMENT SYSTEMS
There are certain key issues which affect the governance and management systems to facilitate a partnership, such as conflict of interest, tokenistic participation in programme planning, incompetent monitoring systems, and unrealistic capacity building systems.

LOCAL PARTNERSHIPS
Many participants advocated for paying more attention in strengthening local level partnerships. A strong and active TB partnership on the frontline can effectively feed into and impart strength to state- or national- level partnerships. This will also address genuine representation of affected communities in TB responses at local, state or national level and will also improve their participation in discourses related to TB responses.

NO SELF-SUSTAINABILITY PLAN FOR PARTNERSHIPS
A participant said: “Partnerships can be a means of mobilising resources for the partners. However in most cases the resource mobilisation is from external sources and there is no self-sustainability plan available. When money dries, the partnership withers.”

STRIKING A BALANCE
A participant said: “It is also important for partnerships to strike a balance between alignment with national policies and strategies, and keeping an independent voice that helps feed into strengthening these policies through a watchdog approach.”

SAFE SPACE FOR CIVIL SOCIETY DOESN’T EXIST IN EVERY COUNTRY
A participant said: “Governments should give an equal opportunity for civil society to get engaged in TB responses. In many countries, it is difficult to believe that governments will not 'control' such partnerships thereby negating all the good we want to achieve by civil society engagement.”

ONE PARTNERSHIP, ONE AGENDA, UNITED RESPONSE
“Without a unifying and common or shared agenda such discussions of working in partnerships and then partners working amongst each other will go in circles. The donors should invest money in shaping such a platform where members can agree on an agenda reflecting needs of communities, mobilize resources and implement effectively” said a participant. Another participant added: “Partnerships exist - but to strengthen them will require a platform where all members can participate as equals - not a partnership where some are more equal than others. That is why coordinated response is a challenge - especially when dominating government agencies and their handpicked or favourite NGOs rule the show.”

TEACHING BY PRACTICE
Partners should establish standard workplace policies related to HIV, TB, sexual and reproductive health, gender and other issues within their organisation before asking the entire Partnership to take a stand. This will not only reduce staff vulnerability but also build an enabling workplace environment.

MUTUAL TRUST AND RESPECT
A participant said: “Good partnership only can exist, if mutual trust and respect can be realized. If not, competition, jealousy even animosity, may be inevitable.” To make a partnership successful, there must be respect for individuals and agencies it works with, whether they are the person directly impacted by TB or the staff of a TB organization. Another participant said: “Building a solid relationship based on trust, understanding, sincerity, and flexibility has enabled us to create a family feeling for the individuals and organizations we have partnered with over the years. We have worked with local health jurisdictions, private and public TB organizations, universities, government agencies, advocacy/education organizations, media outlets, individual donors, churches, and community businesses.”

GENDER
A participant said: “These partnerships on TB must ensure they have well representation of different genders. Preferably they should be led by other genders than a man. It is important to recognize and let other genders take leadership and be given such opportunities - and supported by the entire partnership when they convene. For example, in western UP [a state in India] which is a very patriarchal society, unless women are engaged in leadership roles, how else will TB programmes become gender sensitive to their needs, challenges and what works and what doesn't work with them? So is true for others in more severity like transgender populations - these are important voices and communities know best - and only these voices can help programmes reach the unreached.

RIGHT IN HEALTH BUT NO RIGHT IN GOVERNANCE?
A participant said: “What about nations where civil society generally is struggling for basic human rights but is expected to run democratic, ideal, equitable and just partnerships on TB? Is it because of the funding? That is why our responses on TB must accommodate programmes addressing social determinants of health and social justice.”

NATIONAL PARTNERSHIPS MAXIMISE EFFORTS OF EXISTING STATE AND NON-STATE ACTORS
A participant said: “The partnering process allows national partnerships to maximize the efforts of existing state and non-state actors; bring more services and awareness-raising campaigns to the people, where they are; give a unified voice to non-state partners; and serve as a platform to develop funding proposals and implement grants.”

PRINCIPLES OF EQUITY
A participant said: “People who are doing the service provision on the frontlines are least remunerated - and those sitting on top of TB responses either at the state, country or global level, are heavily remunerated - compare the remuneration please. This inequity has to stop in the development sector and let us have some balance to strengthen country responses to TB.”

UNITY
A participant shared: “…the Partnership provides a voice of a unified civil society in engaging with the government in TB care and control through efforts like providing recommendations into the program planning of national TB programme”

PARTNERSHIPS BUILD TRUST BETWEEN MULTIPLE SECTORS
A participant said: “… the partnership is building trust and collaboration between multiple sectors involved in TB care and control initiatives, through national and regional consultations, with equal participation from all sectors to brainstorm on collaborative efforts and have various channels for communication and sharing of experiences among partners.”

DEFINING ROLES AND RESPONSIBILITIES WITHIN A PARTNERSHIP
A participant shared: “Some of the challenges faced during the formation and functioning of the Partnership include interacting with the different mindset of a variety of partners from diverse sectors ,defining roles and responsibilities of the partnership acceptable to all stakeholders; and defining a governance system maintaining equal representation.”

Bobby Ramakant serves as the Director (Policy and Programmes), CNS: www.citizen-news.org and is a World Health Organization (WHO) Director-General’s WNTD Awardee 2008.

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