The Global Fund and tuberculosis in Nicaragua: building sustainable capacity?

OBJECTIVE The purpose of the study was to explore and provide feedback on local stakeholders' experiences with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) as it related to capacity building for tuberculosis (TB) services in Nicaragua. METHODS An ethnomethodological approach was used to capture the experiences of three different groups: service providers, service recipients, and decision-makers. Data collection involved reviewing secondary texts and records, participant observation, and in-depth interviews and focus groups in both rural and urban municipalities. RESULTS Stakeholders felt that Nicaragua's Global Fund project improved TB control, built human resource capacity and strengthened community involvement in TB programming; however, they noted several contextual and structural threats to sustainable capacity development. The nature of the GFATM's performance-based evaluation de-emphasized qualitative assessment and, at times, created pressure to meet numeric targets at the risk of decreasing quality. Contextual challenges often determined or limited the potential sustainability of activities. Two examples (training volunteer health workers and establishing TB Clubs) from the broader study are offered here to highlight these challenges from health systems and community perspectives. CONCLUSIONS Current approaches to GFATM evaluation and accountability may compromise its positive impacts on capacity building in Nicaragua. Greater consideration needs to be given to ensuring more comprehensive evaluation of project implementation.