Despite the reforms that are associated with the new funding model (NFM), challenges remain “in the inherent structure and paradigm of the Global Fund.” The lack of country offices has many negative downstream effects, including having to rely on in-country partners, and ineffective coordination of in-country activities.
These are some of the main conclusions of a study conducted by a team of researchers, led by Ashley Warren, from the Swiss Tropical and Public Health Institute and other institutions in Switzerland and published in the journal Globalization and Health in December 2017.
The objective of the research was to understand how the Global Fund was experienced by key stakeholders in Maputo, Mozambique; and how recent reforms were experienced by stakeholders in Mozambique as well as by Global Fund stakeholders in Geneva, Switzerland. The data was collected as part of a larger study on the influence of emerging donors in health development.
Thirty-eight interviews –– all but one done face-to-face –– were conducted with persons based in Maputo and Geneva. The Maputo respondents included local fund agents, country coordinating mechanisms, principal recipients (PRs) and sub-recipients. The Geneva respondents included staff of the Secretariat and members of the Board. Multilateral and bilateral partners, some based in Maputo and some based in Geneva, also participated.
Editor’s note: In interpreting the results of the study, there is a serious limitation: Even though the study results were only recently published, most of the interviews were conducted over four years ago, in late 2013 (five Geneva interviews were conducted in mid-2015). Nevertheless, we feel that the study raises some interesting issues.
The study found that because of weak managerial and absorptive capacity in Mozambique, more oversight is required than is afforded by country team visits. Respondents said that country teams were over-worked and, therefore, sometimes unsuccessful as the channel for communication; that too much depends on one individual, the fund portfolio manager (FPM); and that the country teams are out of touch with the realities on the ground.
“The Global Fund does not put things on their website to communicate widely with stakeholders, including at the country level. They rely on fund portfolio managers and people on the country team.”
–– Civil society respondent
One in-country respondent said that “the availability of expertise within the team is country-dependent. … Personnel are over-worked and over-extended and, as a result, it is not uncommon for them to take extended leave. This has caused detrimental gaps in communication.”
Although most respondents said that increased country visits under the NFM were a good thing, one Secretariat staffer took a contrarian view: “Countries also complain that country teams come too often. There is not enough time to make progress between visits, they are constantly working for the next visit, and this increases the time stress.”
The study found that although decision-makers in Geneva recognize in-country coordination as vital to successful implementation, and other actors in-country would welcome Global Fund engagement, to date there are no institutional requirements for formalized coordination. At the time of the interviews, the researchers said, the Fund had no consistent representation in any in-country coordination groups despite a focus on performance-based financing (PBF).
Mozambique has a Health Partners Group that meets monthly and brings together all health sector supporters, including representatives of civil society. In addition, the researchers said, many coordinating bodies have been created as a result of the country’s absorption challenges. These include the G19, a group of bilateral donors who provide sector-wide support and coordinate among themselves, the National AIDS Council, and NAIMA+, a network of NGOs working on HIV and health.
“However, as there is no country presence, the Global Fund itself doesn’t participate in coordination bodies,” the researchers said. “Engagement with the Health Partners Group would greatly enhance the Global Fund’s understanding of country-level activities as this coordination body is a clearing house of what each partner is doing.”
In-country partners provide much needed support for Global Fund recipients, the researchers said, “but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership.”
One Secretariat staffer put it this way: “The big problem has been basically from the creation of the Fund that technical partners are very important; they are the ones who are present on the ground … And many of the countries depend on the technical assistance and the guidance from these technical partners. … It works already quite well in some countries and less well in others. And the challenge is to get more consistent … quality of technical assistance….”
The researchers stated that the degree of external support required for the Global Fund’s success has raised a debate on accountability. “To whom are the providers of TA … accountable?” they asked. One Board member said that “the most difficult part of the Global Fund model is the partnership model. [The Fund] depends on the support of partners and yet it doesn’t have any say over the partners. … I think we need to figure out what that relationship should be.”
Respondents in both Mozambique and Switzerland voiced concerns about the combination of (a) weak country presence, oversight and guidance on the part of the Global Fund Secretariat; and (b) stringent and cumbersome requirements for monitoring and evaluation (M&E) linked to PBF. The researchers said that the principles of PBF are better understood in Geneva than in Maputo where they appear to be overshadowed by the administrative burden placed on PRs. “Until countries take full ownership of this process and are empowered by the intended purpose of performance-based financing,” the researchers said, “PBF will likely continue to be perceived as an administrative burden and identified as a siloed donor demand.”
Ability to reform
Multiple respondents referred to the Global Fund’s ability to reform as one of the defining characteristics of the organization. “[The] Global Fund has proved in 10 years to have the ability to renew itself,” said one respondent from a multilateral organization.
“Overall, the Global Fund is learning from its mistakes,” said a Board member. “[It] completed its reformation in one year. It is a ‘learning organization’; it is navigating through a field of opposing forces and is highly committed to its mission.”
Although many of the reforms have not yet addressed concerns about the Global Fund’s overall model, the researchers said, respondents seemed to be looking beyond this initial transformation. They clarified that although their comments were critical of the Global Fund, they admire the Fund’s work.
Not having a country presence has obvious drawbacks, as the researchers indicated. What the researchers did not mention in their article is that there would be serious costs associated with having a country presence.
When asked to comment on a draft of this article, Seth Faison, Director of Communications, pointed out that, from its founding, the Global Fund has avoided country presence for two overarching reasons: First, the Fund believed in the principle of country ownership where local experts are the ones who can best lead implementation work. Second, the Fund believed that limiting all staff to one office in Geneva would maximize the amount of funding available for grants and would minimize operating expenses.
“If the Global Fund established an in-country presence in countries with significant grants,” Faison said, “it would likely require increasing operating expenses by a significant margin. How much exactly would obviously depend on how much country presence. But allowing some country presence would likely lead to requests for more.”