The Global Fund’s Strategy Committee plans to discuss country coordinating mechanism (CCM) evolution next week. These discussions come about three years after the Office of the Inspector General (OIG) published an audit on CCMs (in 2016); and about a year after the Global Fund launched its CCM Evolution initiative (as a pilot project in 18 countries) and adopted a new CCM policy and code of conduct.

The OIG’s audit of CCMs enumerated a list of issues, among them: little integration of the CCM into the national systems in several countries; weak governance structure; and a sub-optimal oversight system. The OIG suggested strengthening the capacity of the membership and leadership of the CCMs.

Some of those issues are recurrent and had been highlighted earlier. The Secretariat has tried to address some of them through the CCM Evolution initiative. The initiative aims to improve the performance of CCMs in four main areas: CCM functioning; linkages with other national forums; oversight to maximize grant performance; and engagement.

(See also previous GFO articles on the Tanzania CCM aspiring to be a best practice model and a workshop in Morocco for consultants supporting CCM evolution.)

It is important to maintain a focus on CCMs. This commentary presents a few ideas to deepen the reflection on this critical area.

1. CCMs have broad representation and a significant role to play

CCMs are composed of representatives from government, civil society, private sector, persons living with or affected by the three diseases, and multilateral and bilateral agencies. At the time the CCM concept came into being, such broad representation was innovative and particularly important in the context of Global Fund principles, especially those of partnership and country-ownership. CCMs’ role, according to guidelines approved by the Global Fund Board, include coordinating the development and submission of national requests for funding; overseeing the implementation of grants; approving reprogramming requests; and ensuring linkages and consistency between Global Fund grants and other national health and development programs.

2. CCMs have the potential to be real partners of the Global Fund

The High-Level Review Panel report in 2011 called CCMs “cornerstones of Global Fund architecture” within countries. As such, they should be partners of the Global Fund Secretariat overseeing grants and, when necessary, recommending to the principal recipient (PR) actions that can improve grant performance in countries. Such a role can be effective and efficient if the CCMs truly have broad representation and if they have a capable CCM Secretariat.

Some CCMs members, speaking on condition of anonymity in order to be able to talk candidly, have complained that they are sidelined both by the Global Fund and the PRs after the submission of funding requests and the grant signing ceremony. (Grant agreements are signed between the Global Fund and the PRs.) They explained that during grant implementation, the Global Fund seeks them out only in case of problems, such as a non-performing PR, or to follow-up on co-financing requirements. While such complaints target the Global Fund Secretariat and the PRs, they also suggest deficiencies in the leadership and functioning CCMs.

3. Strong CCM leadership is necessary to obtain good results

Strong CCM leadership is vital for Global Fund grants’ performance and sustainability. Such leadership occurs –– not always but often –– when the CCM chair holds a recognized leadership position in government, especially in countries where the CCM is not integrated into the national health system. In this way, CCM chairs can bring their influence to bear on issues that are vital for Global Fund grants, such as meeting domestic and co-financing requirements, obtaining tax exemptions, and getting governments to grant privileges and immunities.

Conversely, when the leadership of the CCM is not perceived as influential, the CCMs have a harder time implementing decisions. The CCMs’ decisions and recommendations can then be ignored with no fear of repercussions because its leadership lacks the influence (perceived or real) that come with a position of authority in the government.

This idea of strong leadership often vested in government officials clearly goes against the practice in some countries of excluding government implementers from important CCM discussions on key implementation matters because of a conflict of interest (COI) policy. While all members of the CCM are equal (see CCM Policy) and it is important to ensure they can all speak their mind, such an understanding of the notion of COI is preposterous: The COI requirement is designed to prevent fraud and corruption, as clearly stated in the Global Fund Policy to Combat Fraud and Corruption. The COI requirement does not aim to exclude State PRs from discussions that concern them and decisions that they would ultimately implement. Such exclusion may negatively affect grant implementation.

4. Civil society organizations are vital components of the CCMs

The presence of civil society organizations (CSOs) is vital not only for the proper design and implementation of grants but also to keep government actors accountable. This fact cannot be underestimated given that state PRs administer about 60% of all Global Fund grants.

5. CCMs should be appropriately funded, and represented

Effective, efficient and functional CCMs and their respective Secretariats require competent personnel, in adequate numbers, as well as the necessary working tools.  The Global Fund and its partners should invest in the CCMs and their Secretariats human resources and other tools. In particular, the representation and oversight functions of the CCM should be strengthened with adequate staffing considering country context and size of the portfolio.

CCM members are volunteers who represent their original institutions such as CSOs, government, and donors. CCM members’ day jobs are to represent their primary employers/institutions – not to represent the CCM or the Global Fund in other instances. For example, in health sector meetings in some countries, rarely do participants discuss the Global Fund strategic policies and how those are aligned with domestic ones, even though many members of the CCM may be present. This weakness in CCM representation could be remedied by the presence of competent professional employees of the CCM Secretariat.

6. CCMs should be sustainable, integrated into the national system and linked with other institutions

In many countries, the CCMs are not integrated within the national health system architecture. Rather, CCMs created for and by the Global Fund serve the purposes of the Global Fund. In that context, the finding in the OIG’s 2016 audit of CCMs that in nine countries where the Global Fund withdrew its support, the CCM ceased to exist is not surprising, though it is unfortunate.

Another global health initiative, Gavi, the Vaccine Alliance, has created a structure similar to the CCM called the Inter-agency Coordinating Committee (ICC), which is a national coordination forum in each country with government leadership; and most bilateral donors have steering committees for their own in-country programs. Many representatives of government, CSOs or donors among the CCM membership also hold a seat on the ICC or other, similar, coordinating bodies.

At a national level, it is important to create an entity capable of fulfilling the combined coordination and oversight role that the Global Fund’s CCM, Gavi’s ICC, and other similar bodies created by third-party funders fulfil seperately for their respective donors. Merging such bodies could create synergies, increase a sense of country ownership, and help build health systems at time when countries are moving toward universal health coverage.

Some countries, such as Rwanda or Chad, have set up unique structures for the management of all donor grants such as those from the Global Fund, World Bank, Gavi and other bilateral donors, to increase efficiency and avoid duplication. It is not a stretch of the imagination to think that if grant management across funders can be successfully merged, so could their coordination mechanisms; and that those coordination mechanisms could become cornerstones of the national health architecture.

Ida Hakizinka is Aidspan’s Chief Executive Officer, and Djesika Amendah is Aidspan’s senior policy officer.

Note:

The GFO will publish additional articles relating to the CCM evolution initiative in future issues.