Meaningful participation of civil society in country dialogue has been a central pillar of the Global Fund’s New Funding Model (NFM). Money has been invested, meetings have been held, and documents have been published. But did it matter? A new report released by the Eastern Africa National Networks of AIDS Service Organizations (EANNASO) measures the impact of civil society consultations on the final concept notes submitted. Notes submitted by Kenya, Malawi, Swaziland, Tanzania, Uganda, Zambia, Zanzibar and Zimbabwe were examined for how responsive they were to priorities identified by civil society during country dialogue. The civil society priorities charters, published by AIDS Accountability International, were used as a measure of what national civil society organizations wanted to see included in the concept notes. Using a three-point scale, alignment was assessed between priorities in the civil society charters and interventions that were included in the concept notes (2 – included; 1 – partially included; 0 – not included). Each country was then given a score, expressed as a percentage. All the concept notes that were analyzed were integrated TB/HIV concept notes except for Zimbabwe, where a standard concept note for TB was used (due to early applicant status). The analysis demonstrates wide variations in responsiveness (Table 1). Malawi’s concept note was by far the most responsive to civil society priorities (at 87%) while Zambia’s was the least (at 38%).
Table 1: The Responsiveness of Global Fund Concept Notes to Civil Society Priorities

Country	Score	Level of Responsiveness to Civil Society Priorities
Malawi	87%	Extremely Responsive
Kenya	76%	Highly Responsive
Tanzania	67%	Moderately Responsive
Zanzibar	67%	Moderately Responsive
Uganda	64%	Moderately Responsive
Swaziland	50%	Mildly Responsive
Zimbabwe	40%	Limited Responsiveness
Zambia	38%	Limited Responsiveness

The results also indicate a ‘triaging’ in priorities, with some more likely to be included than others. Issues related to key populations took precedence, followed by interventions focused on behavior change. The intervention area where civil society had the least impact was voluntary medical male circumcision (VMMC). Just 15% of civil society’s VMMC priorities made it into the final submissions. This is unsurprising; civil society has comparatively less experience in bio-medical issues than government. The report offers several explanations for the range of influence of civil society on national priority setting. A statistically significant relationship was found between the World Bank’s Governance Indicator on voice and accountability and the responsiveness of the concept notes to civil society priorities. This means that countries with a greater degree of freedom of association and freedom of expression submitted concept notes that were more inclusive of civil society asks. Countries with more effective governments and rule of law were also more likely to submit concept notes that responded to civil society priorities, though these were not statistically significant. Public opinion data from the Afrobarometer Survey also helps to explain civil society’s success in influencing Global Fund concept notes. One survey question asks if people agree with the statement “It is more important for citizens to be able to hold govern­ment accountable, even if that means it makes decisions more slowly.” The results of the EANNASO study show that in countries where more people strongly agreed with the statement, civil society was more successful in influencing Global Fund concept notes. Another question asks “Do you attend community meetings?” In countries where more respondents answered “yes, often”, civil society also had greater impact on the concept notes. Third, in countries where more survey respondents said they often join others to raise an issue, the Global Fund concept notes were more responsive to civil society’s priorities. All of these relationships are statistically significant. The report also probes whether including civil society priorities matters for key funding decisions. From the selected sample of countries, concept notes from Zambia (the least responsive in the study’s sample) and Zanzibar (moderately responsive) were returned by the Global Fund for reiteration and resubmission. The reason for this – as confirmed by the Technical Review Panel – was in part due to the need for greater inclusion of civil society priorities, particularly those of key populations. Another outcome variable tested was disease burden. The study finds a statistically significant relationship between HIV prevalence and the responsiveness of concept notes to civil society priorities; countries which submitted concept notes that were more responsive to civil society had lower HIV prevalence rates. The authors of the report call for further investigation into this finding, particularly using lagged prevalence data to determine if inclusion of civil society priorities is associated with better disease outcomes five and ten years down the road. The report concludes that an inclusive country dialogue had a positive effect for civil society in some countries but not others. The statistical analysis reveals that the context in which civil society operates has strong bearing on how effective it can be at influencing Global Fund decision-making. For this reason, the report recommends that funding partners invest in aspects of community systems strengthening which empower civil society organizations to mobilize and discuss their issues freely. Recommendations also include replicating the methodology to assess civil society’s influence in other spaces, such as with the US President’s Emergency Plan for AIDS Relief (PEPFAR) Country Operation Plans, or with National Strategic Plans. While this is some of the only existing evidence of the impact of civil society consultations on Global Fund decision-making in the NFM, it could have implications for the Fund’s new strategy. Certain factors appear to support positive outcomes of civil society participation, which can be fostered with further investment. However, there is a need to further interpret the results of the report, understanding how nuances at country level may have played a role. EANNASO is currently conducting follow-up research in six of the eight countries, to further understand what makes for a successful country dialogue for civil society.