When the Global Fund Secretariat, through its CCM Evolution project, invited embers of the Tanzania National Coordinating Mechanism (TNCM) to stakeholder consultations in 2017, it captured the attention of TNCM stakeholders. The consultations resulted in the launch of an ambitious and innovative process to transform the TNCM into an effective and efficient organisation with the capacity to maximize its management of all health-donor funds for the three diseases and health system strengthening. A driving force behind the desire for reform is Tanzania’s recognition that, after more than 15 years of Global Fund support and the investment of nearly US$1.8 billion (second only to Nigeria in the total amount of Global Fund investment), programmes have not performed as well as expected. This is in addition to the even greater resources provided by the US President’s Emergency Fund for AIDS Relief (PEPFAR).  The development, management, implementation and evaluation of disease programmes still face the same familiar challenges and bottlenecks from year to year.  Hence, the best health outcomes are unlikely to be attained until the framework for programme delivery has improved.  Without essential, well-functioning management components in place, Tanzania is unlikely to improve its health performance and maximize the most effective and efficient use of donor support. Three decades of experience with CCMs have provided a wealth of information on their weaknesses and opportunities for improvement, leading the Global Fund to acknowledge that CCMs cannot continue to operate in the same way if countries are to better implement the Global Fund Strategy 2017-2022.
Development of the Global Fund’s “evolution approach”
As a result, in 2017 the Global Fund Secretariat conducted a series of consultations on CCM evolution (the CCM Evolution Project), to examine how CCM functionality and performance could be improved.  Data collection, analysis and a series of consultations with multiple stakeholders identified the need to strengthen the quality of engagement of CCM members, clarifying expectations for CCM oversight and strengthening CCM linkages to national bodies, tailored to country context.  At the 38th Board meeting in November 2017, updates were provided on the key findings to date, options and next steps.  The Board agreed that the Secretariat would evaluate options based on potential cost and impact to discuss with the Secretariat’s Committees in March 2018 and at the 39th Board Meeting in May 2018. The May 2018 Board meeting approved the first phase of “an evolution approach”, called the CCM Evolution Initiative, endorsing the consultations’ findings on the three main changes needed to evolve CCMs: (1) differentiate CCMs according to context into Standard CCMs, Transition Preparedness CCMs and CCMs in Challenging Contexts; (2) improve CCM performance in key areas, including the approval, introduction and enforcement of a Code of Conduct; and (3) introduce CCM maturity levels (functional, engaged, and strategic) tailored to different types of CCMs. Specifically, the Board approved the revised ‘Guidelines and Requirements for CCMs’ (now renamed the ‘CCM Policy’), the Code of Ethical Conduct for CCM members, and funding to support the first phase of implementation for CCM evolution in selected countries for 2018-2019. The Board then discussed the proposed four options concerning the level of ambition the Secretariat should have regarding CCM Evolution, and each level’s recommended funding. The level of ambition is the extent of the scope and number of countries the Secretariat can actively support to integrate operational changes.  The Board accepted the Strategy Committee’s recommendation of a phased roll-out of the Intermediate option and allocated US$3.85 million to be made available to implement activities in 2018 and 2019 through piloting the Initiative in 18 targeted countries, of which Tanzania is one.
Table 1: 18 countries participating in first phase of CCM Evolution Phased Approach

Standard CCMs	Transition preparedness CCMs	CCMs in challenging contexts
Benin Burkina Faso* Cameroon Lesotho Malawi* Mozambique Nepal Papua New Guinea Tanzania* Uganda	Albania Colombia Guatemala Romania	Burundi Congo (Democratic Republic) Haiti Niger

Tanzania’s readiness for CCM reform
In addition to the CCM Evolution Initiative, other events influenced Tanzania’s readiness for TNCM reform.  Firstly, Tanzania was one of several countries reviewed by the OIG for its 2016 global CCM Audit, the findings of which were central to the Global Fund’s decision to move forward with CCM evolution. In early 2017, TNCM performance (along with that of many other countries’ CCMs) was assessed by an independent team, as part of the early activities carried out during the research and data collection phase of the project. Likewise, in 2017, the Health Economics and HIV and AIDS Research Division (HEARD) of the University of KwaZulu-Natal, supported by the Bill & Melinda Gates Foundation (BMGF), conducted exploratory research on Global Fund processes in Tanzania. This assessment provided lessons learnt and an analysis of the gaps and challenges that will provide invaluable information as Tanzania proceeds to evolve its CCM.  Finally, selected TNCM representatives attended CCM Evolution workshops in Ethiopia (2017) and Malawi (2018).  Transformation was thus a key issue for the TNCM’s new dynamic Chairman, Professor Faustin Kamuzora, Permanent Secretary (Policy and Coordination of Government Business), who no longer wanted to see ‘business as usual’ when it was clear that this had not produced optimal results.  And the time was ripe: not only was there a new Chairman but newly elected TNCM members would be in place by the end of 2018. The finalization of HEARD’s research coincided with the Global Fund’s move to assist CCMs to reassess their roles and develop into more effective mechanisms.  Tanzania is keen to make the most of this opportunity to bring about changes that will ultimately improve health outcomes. Being one of the 18 pilot countries represents a unique opportunity for Tanzania to develop a best-practice model on how to successfully transform a CCM. The starting point for reform is the country’s supervision of Global Fund processes.  Good management, at a CCM level, implies that the TNCM has to function well and proactively; plan for and manage problems and risks rather than react to them; be assertive, professional and competent in dealings with the Global Fund; and establish and maintain a favourable programme delivery environment.  Once this has been achieved, Tanzania will be in a much better position to tackle programme-level issues.
Gates Foundation support for TNCM’s 18-month transformation period
As a result of the assessment’s recommendations on how the TNCM could improve its management of Global Fund processes, the Secretariat requested BMGF to support transformation over an 18-month period.  This requires the development of a transformation plan to improve TNCM operations and performance so that it becomes an efficient and proactive organisation capable of providing real leadership, governance and oversight to health program implementation. The first action for TNCM was to build consensus for reform among committee and program stakeholders.  To do this, the TNCM held its first ever residential retreat in August 2018 for TNCM members and alternates, together with implementing partners.  Over 50 participants attended, comprising a balanced representation of Government and non-government programme delivery managers, Principal and Sub-Recipients (PRs and SRs), the Local Fund Agent, civil society and faith-based organisations, academic institutions; and key development partners.  The presence for three days of two Permanent Secretaries demonstrated the importance attached to the transformation process. The retreat aimed to achieve agreement on a way forward that would contribute to the development of a transformation plan.  Participants were presented with management and planning tools that could help the planning process and keep the momentum for change.  The tools included: the evaluation methodology of appreciative inquiry to reflect on recognised performance and implementation issues; SWOT analysis to arrive at solutions to address threats and weaknesses while taking advantage of strengths and opportunities to upgrade the TNCM’s performance; a theory of change, using the SWOT analysis to populate it and address major concerns; and stakeholder analysis to win support, gain resources and achieve consensus.  Participants considered these tools to be useful, and the same tools could potentially be used by other CCMs embarking on an evolution process. The four major enablers to evolve CCMs to the highest functional level, that of Strategic Engagement, were discussed; and participants felt that three of four enablers were now in place — having the right leaders, an effective CCM Secretariat, and strong support and active engagement from the Global Fund Secretariat.  It was recognised that there needed to be a formal transformation plan which, in addition to the changes sought, should also include work on the fourth enabler: having sufficient financial resources. The enablers are intended to support the four “improvement areas” identified by the Global Fund: functioning, linkages, engagement, and oversight. The TNCM now has to review the 18-month CCM Evolution workplan provided by the Global Fund and develop and implement its own transformation plan in such a way that it is consistent with the CCM Evolution activities planned for Tanzania. If the momentum for change is maintained, as the first country to take ownership of the CCM Evolution Initiative and move beyond the minimum required by the Global Fund, Tanzania could be in a position to provide a model for other countries’ successful CCM evolution.
For more information on the CCM Evolution initiative, see also:

• “Global Fund Board approves CCM Evolution initiative at an intermediate level of ambition but with a phased-in approach” from GFO 336 (12 May 2018)
• The Global Fund’s CCM-related document from its 39^th Board Meeting: “CCM Evolution: CCM Code of Conduct, CCM Policy and Level of Ambition”
• The Global Fund’s CCM Evolution description on the CCM page of the Fund’s website

• The Global Fund’s CCM Policy