Are Country Coordinating Mechanisms a modus operandum, a governance ideal or a tool for countries to progress towards universal health coverage?
When the Global Fund was born...
When the Global Fund was born as a response to an emergency, it was clear that this new institution would be governed by rules different from those of existing organizations. We wondered about the modus vivendi, the model business for a "cash kitty" created in an emergency, responding to the needs identified by the countries themselves in their strategic plans to fight against HIV/AIDS, tuberculosis and malaria. Putting the country and its "ownership" at the center of its model, the Global Fund – because it did not wish to be a classic ‘colonialist’ organization, as a point of honour elected not to have representation in the countries.
At that time, in the early 2000s, HIV/AIDS affected a defined category of people who automatically seemed guilty of ‘shameful’ behaviour, at best considered ‘risky’. People living with HIV/AIDS (PLHIV) were quickly stigmatized, discriminated against (and in turn felt guilty, frightening because of being contaminating and contaminated, by a ‘shameful’ exterminating virus, unknown in existing medical protocols, frightening even, and especially, the medical establishment.
It was therefore clear that resources should benefit PLHIV, and for that they needed a voice and representation. The discrimination and stigmatization of HIV was too strong for those affected to be able to publicly defend their interests, except for some courageous souls in the North and the South, to whom we are still indebted today.
Who will speak on their behalf? Defend their cause? Cover their need?
But if the Global Fund did not have in-country representation, how could the transparency of grant management be ensured? Who would check the equitable distribution of resources to cover the less obvious needs of the fight against HIV/AIDS between the various actors, in particular between the public sector and the non-governmental sector? It goes without saying that this remains the primary question of civil society organisations (CSO) and people living with the disease.
Hence a great stir and vigorous advocacy by community representatives was launched to guarantee the rights and resources of PLHIV and those most at risk, which today are called key populations.
The Global Fund, under a double constraint (its vision of non-representation /non-interference in the country's program and the need for the representation of PLHIV and key populations) would opt for a model that looks like its own organization: the Country Coordinating Mechanism – multisectoral, a partnership, which is not involved in the implementation of the grant but acts upstream in the orginal design and definition of the programs submitted to the Global Fund, flowing from the country’s National Strategic Plan, aligned to the needs of the populations.
At the beginning, the CCM was a club of primary and secondary recipients, specialized in HIV (as was the UNAIDS thematic group, dissolved with the arrival of the CCMs), TB and malaria. And on the way, the more the Global Fund changed its guidelines, the more the CCM expanded in response. Often, and unfortunately, expansion of the number of members and functions did (and does) not necessarily mean an improvement in performance.
Today, 17 years later, the Global Fund continues to refine the model of the CCM, a sign that adjustments made so far to the CCM have not worked. Admittedly, some progress has been observed: the ‘verticality’ of medical care is out of date thanks to the strengthening of health systems, the communicating channels between TB, HIV, and malaria programs are in place, as well as the integration of HIV into more specific programs. But the main challenges remain and we need to be bold enough to confront them if we want to see the CCM survive and function effectively.
The main challenges persist
The moral and legal character of the CCM is a hindrance to its institutionalization.
Nothing obliges a country to institutionalize the CCM and some of them function without institutional anchoring. In some countries where key populations are criminalized by the criminal justice system, it is unacceptable to the prevailing authorities that a ‘democratic’ coordinating and monitoring body exists and continues, an inconsistency with the very concept of the CCM. The question of the portfolio manager's interest in the CCM also arises in this context – the strength of the CCM also depends on the recognition and place given to it by the Fund Portfolio Manager.
A CCM's leadership can be a game changer, but it depends on the cultural and political context of the country. In that sense, the training provided by the CCM Evolution initiative is not relevant – the Presidents of the CCMs are usually high-powered figures who do not need ‘training’, but rather need time and opportunities for reflection and dialogue on related high-level strategic issues such as health financing, integration of services, domestic financing, and more.
Democracy within the CCM versus democratic functioning in the country?
Consider the contexts used in the strategy of evolution of the CCM: Standard, Challenging Operating Environment (COE), Transition – interesting technical categories but which should be coupled with the cultural and political context, because the rules of governance and good management are sometimes in contradiction with the country’s use of the CCM. If we have a look at COEs, for example, we should analyse them as ‘standard’ countries embroiled in a humanitarian crisis (Haiti earthquake), health (Ebola), security (Burundi in 2015, Somalia, Sudan), that may hamper to some extent the functioning of the CCM.
More important is the impact of criminalization on key populations and their participation in the CCM. How is the democratic context and the exercise of democracy outside the CCM taken into account? In some countries where the political system is not based on democratic foundations, as they are commonly understood (power belongs to the people who choose their representatives, and as far as possible the judicial, legislative and executive powers are separated in order to guarantee independence and good governance goes accountability), is not the CCM an idealized and completely grounded representation of governance habits? This is tantamount to the fundamental question of whether adapting the governance model proposed by the CCM – a very Western, democratic, idealised image of partnership that is not anchored in the realities of many developing countries – is feasible, is a more idealized governance system than good practice, and one that is more in keeping with the ideal of representation and collegiality of Global Fund than the reality of a number of countries in which they are implementing. And this explains the difficulties of bringing into conformity certain CCMs, which are really struggling to apply rules that are not intrinsically anchored in a socio-cultural reality.
The unrealistic role that exceeds the authority of the CCM and its prerogatives if the CCM is not institutionalized.
The CCM in general does not usually have representatives from the country’s Ministry of Finance, whose own skills could enhance the CCM’s understanding the budgetary provisions of financial law. The CCM also does not have the authority to influence the government's proposed budget bill, unless someone from the Ministry of Finance is, in fact, a member of the CCM, and takes its role on the CCM very seriously.
In addition, there is too much emphasis placed by the Secretariat on strategic oversight. When strategic oversight – follow-up of grants’ performance in terms of epidemiological impact – is assessed as highly functional, it is because the strategic oversight committee (usually there is one within the CCM) is composed of skilled people who often look at specialized technical and programmatic aspects that go far beyond the field. It becomes a technical and not a governance committee, and in this case, the CCM could claim to have an influence on some results of the grant, but of course not all because they depend mainly on the ability of the Principal Recipient (PR), sub-recipient (SR) and sub-sub-recipient (SSR) to implement programs in a given health system. The number of meetings and minutes shared are not a measure that will reflect a CCM's performance, in terms of strategic oversight.
The positioning of civil society
There is a need for a paradigm shift especially for activist representatives, whose positioning must be adapted to fit this specific gathering, where they will face technical and financial partners, high-level ministers’ representatives or members of the private sector: it requires training in communication, in meeting representation, before, after, and during the CCM sessions. The CCM Evolution initiative addresses this point, but how to enable the civil society representatives on the CCM to change the way it interacts with the rest of actors? How should civil society organizations be organized to have leverage and become a game changer within the CCM? At the same time, we need to review the retro information requirement for civil society (a requirement in CCM guidelines that CS representatives go back to other CS groups whose input has been discussed at the CCM, to inform them about what transpired), especially where it is difficult or impossible for the Key Populations to organize themselves.
And this requirement must also be applied to the public and technical and financial partners’ sectors. But at the same time, compliance with requirements determined by the Global Fund highlights the dangers of rail-roading Civil Society Organizations into a role of representation and sometimes legitimizers of systems that they can no longer denounce independently because they are the stakeholders, and service providers. The "depoliticization" of civil society, the risk of seeing it lose its soul in processes that require too much effort in order to comply with the rules of the Global Fund, whose meaning is often forgotten in favour of respect, becomes sometimes absurd. How to ensure that the CCM allows CSOs to express themselves and play their role as challengers of the public authorities of whom they demand accountability? And respect the rules of governance? By taking on the risks that this makes them run in the countries where they are criminalized?
Number of CCM members vs. quality and effective participation
As CCM guidelines have changed, the CCMs have expanded to include unqualified members (with no health system or disease-specific expertise) to serve on a national coordinating body. Their inclusion was the way to tick the boxes, which many regret after the fact, and is one factor that discredits the concept of the CCM. Quality also stems from consistency, or we cannot ask volunteers – members of CSOs and the private sector who do not receive any incentive – to be consistent. There, the volunteer model imported from the North shows its limits. At the beginning, people were interested in HIV/AIDS because of the devastating effects on society at large. But now, it seems that even the interest of the health professionals fighting against the diseases is less obvious. Especially for TB, malaria and hepatitis, which are more technical and can be boring (proof is the difficulty in finding representatives for TB and malaria). Reducing the number by raising the quality seems a good compromise.
The CCM remains a unique model of national coordination, whose scope is reduced by the legitimate need for standardization through guidelines that are common to all countries, even though flexibility is granted according to contexts. With the CCM Evolution initiative, and previously the evaluation of performance (EPA) measuring functionality and compliance, the CCM as an innovative model will continue to face more critical and structural hurdles. Deep thinking and the courage to question the model are essential for initiating substantive reforms.
If we want the "one size does not fit all" to have any meaning, the following variables must be questioned to design a suitable country model:
- Study ways of institutionalizing the CCM to grant it the necessary authority – to engage with those at the highest levels of national influence – according to the governance and socio-cultural profiles of the countries;
- Clarify the expected results of the CCM Bureau, especially on the most technical topics such as co-financing monitoring, strategic oversight, and links to the rest of the health system;
- To review the concept of volunteering in the light of country experiences and realities, beyond the payment of attendance fees to members, as happens today. This is a necessary debate on the role of the CCM: if it is an informative forum allowing a form of accountability on the activities of the grant, there is no need for advanced technical skills or remuneration; on the other hand, if it is perceived as a monitoring and control body, able to challenge the main beneficiaries on their results, their interventions and the State on the integration of the response to pandemics in the health system and its respecting co-financing commitments, it must undergo a “professionalization”;
- Strengthen the permanent secretariat, by adjusting the role of the Permanent Secretary, who is now fulfilling the functions of a Director General, and adding the relevant staff in strategic monitoring. Of course, depending on the size of the Global Fund portfolio in the country.
- Differentiate the size and representativeness of the CCM according to the context of the country, at a time when the Office of the Inspector General and the Global Fund Secretariat call for more local and rooted solutions designed by the countries themselves.