Country Coordinating Mechanism’s Engagement with Civil Society, Key Populations & Communities – A Conscious Uncoupling?
Author:
Madhuri Kamat
Article Type:Article Number: 5
Has the Global Fund’s non-negotiable about the participation of civil society, key populations and communities been subsumed to the new normal of government-led Country Coordinating Mechanisms (CCMs)? We explore the changed scenario and share details of the Global Fund’s own Assessment Report of CCMs and other voices from the field.
Introduction
At the 42nd Global Fund Board Meeting Report in 2019 a key point for discussion for the Strategy Committee and the Board was, “How can Country Coordinating Mechanisms (CCMs) best succeed in strategic positioning within national structures and/or in merging with existing or emerging coordination platforms? (non-negotiable: maintaining the active participation of affected populations, including key populations, those living with the diseases, civil society)”. The issue of positioning is discussed in another article. The non-negotiable aspect in the brackets is the focus of this article, using sources such as the Global Fund’s Assessment Report 2024 on Country Coordinating Mechanisms (CCMs) as well as other reports and inputs from the field.
Government role in CCMs
In her presentation at GFAN Africa’s February 2024 meeting on the 8th Replenishment Planning, Claudia Ahumada, Global Fund: Manager, Civil Society and Communities Advocacy shared the National Civic Space Ratings of the CIVICUS Monitor 2023, which reported that countries where the Global Fund focuses its work coincide with countries where the threats to civil society advocacy are greatest. Moreover, governments wish to assign service delivery rather than support civil society in advocating for human rights and equitable laws that in any way challenge the government. The impact can be seen in the CCMs.
India CCM
As the government seeks to seize control of the national narrative, NGOs have come under increasing scrutiny. The government cutting off the license to receive foreign funding of some NGOs is one example of restrictive policies. As per the Minutes of the 89th Meeting of the India CCM in August 2023, the Vice Chairperson noted that some activities and budgets of the NGO PR under the Global Fund have been shifted to the Government Principal Recipients (PRs) and she cautioned that optimal resource utilization by the Government PR was a challenge. When prodded for the reasoning behind the shift of higher allocation for the Government PR under HIV, for instance, “it was informed that Government PRs would further engage Indian NGOs and other organizations to undertake activities”. Moreover, supply chain, laboratory and technical support, earlier featured with NGO PR were moved to the Government PRs. There is also a shift of focus to community-led organizations rather than NGOs as representative of civil society. It led to India requesting the Global Fund to “relax its financial eligibility criteria” to enable participation of “networks and community-based organizations” as NGOPR. In the meantime, overall allocation for NGO PR for TB got reduced but doubled for community activities. The CSO-HIV representative also asked that the One Stop Centre be not directly implemented by the NGO PR but through networks and community engagement.
However, while governments dominate the CCMs, it is not that civil society is working any better as the Global Fund’s CCM Assessment Report revealed.
Global Fund’s Assessment Report 2024: Insights From the 52 Endline Assessments:
Although a majority (86%) reported being annually trained on CCMs and on their role, the Integrated Performance Framework (IPF) revealed the following:
- Orientation for only 50% of CCM members was done online or included face-to-face meetings.
- Among civil society members, only 42% had a consistent linking with their constituencies before or after meetings and this was cited as a significant gap by 31% of the respondents although the majority of civil society (79%) engaged in key committees.
- While the majority (87%) of the oversight committees included key vulnerable populations or people living with diseases (PLVDs), strategic data was collected from non-members and PLVDs by only 44% of oversight committees.
- There was no dearth of information sharing between the CCM Secretariat and its members, with the majority (81%) providing adequate information. This finding confirms that one of the key priority areas identified by the majority (70%) of CCMs who were part of the CCM Evolution Strategic Initiative (ESI) pilot study (as mentioned in the 2023 audit report of CCMs by the Office of the Inspector General (OIG)), has been largely attained. More on the ESI can be read in Aidspan.
Given that civil society is represented in 50% of the 110 CCMs and is over 40% in 69% of CCMs that were part of the 52 endline assessments, the above findings do not augur well for the role of civil society organizations (CSOs) in CCMs. It shows that decision making eddies around the CSO representatives alone but does not get passed on to those they claim to represent mirroring the decision flows led by the government. This finding confirms one of the issues raised in the webinar organized by the Stop TB-Global Fund Advocates Network (GFAN) in February 2024: How are representatives to be held accountable?
Voices from the Field
Stop TB-GFAN Webinar, Debrief of the Stop TB Board Meeting, Brazil & ACTION Report, 2024:
Need for Systems, Training, and Best Practices
There’s a pressing need for establishing robust systems that enable meaningful participation from all stakeholders, including marginalized communities. This includes creating comprehensive training materials and disseminating best practices to equip representatives with the knowledge and skills required to advocate effectively. Moreover, it emphasizes the necessity of investing in capacity-building initiatives that strengthen the ability of representatives to engage in global health governance meaningfully.
EANNASO webinar – Global Fund Grant Cycle 7 Community Engagement Experience Sharing in Anglophone Africa, 2024:
In South Sudan, the government supported key populations to participate in the National Strategic Plan, which coincided with the Global Fund GC7. The Technical Assistance from EANNASO facilitated CSOs and communities for priority identification to be financially supported.
Other countries had contrasting experiences. There is glaring social inequity in resources to support communities, in Tanzania, for instance, where people traversed over great distances daily to reach meeting venues while the government representatives were housed and taken care of in government-provided facilities.
In Gambia, a community thematic working group was led by a government institution.
A presentation by Mozambique shared that the disagreements between the priorities of civil society and what communities wanted led to heated discussions. Due to the lack of expertise in fighting for priorities some constituencies may not get their fair share of opportunities in getting heard and hence their due share in the process when budgets get redistributed.
A participant from Kenya shared that often the actual priorities for funding requests get progressively whittled down. But the final document gets to be seen only by the country and funding renewal teams. While ostensibly a basket of priorities is presented, in reality discussions have already taken place behind closed doors about what these will be. In the words of Rosemary Mburu, Executive Director at WACI Health, “Everything you worked on yesterday was missing!”
Currently, it is left to countries and/or constituencies to seek out financial backing to participate in country dialogues. For instance, Zimbabwe’s CCM received funding support from UNICEF to get young people to contribute to priority setting and the National Aids Council supported key populations. The difference that youth representation can make was reflected in the fact that in Ghana, for the first time, youth priorities were included in national strategy plans, with active participation in workshops as well as recommendations for funding requests. However, there was again under-representation of people living with diseases with a youth living with tuberculosis involved with the actual report writing, but not those with malaria and HIV.
Francophone Africa Regional Platform webinar – Global Fund Grant Cycle 7 Civil Society Organization (CSO) Experience Sharing in Francophone Africa, 2023:
Côte d’Ivoire, Niger and Madagascar shared the challenges they encountered: weak internal and external communication at all levels; insufficient participation in the different stages of the process; absence of feedback prior to country dialogue between CSOs in urban centers and those from the interior of the country; weak accountability mechanisms for CSOs within writing groups; choice of CSO participants in the grant process; participation in funding request finalization. For instance, the list of community activities included in the concept notes never made it to the funding request. [Source: Translated from Aidspan French newsletter, OFM]
Youth Engagement in the CCM and Global Fund Processes in the Asia-Pacific, 2022:
In 2022, a situational analysis of challenges and facilitating factors for youth engagement was carried out in 18 countries in the Asia-Pacific. The assessment showed that only seven countries (Iran, Malaysia, Mongolia, Thailand, Timor-Leste, Vietnam and the Philippines) reported having youth representation in CCMs. This was made possible due to political willingness to be inclusive and formalization of their representation as also mentorship and supervision by supportive stakeholders. Further, only half (50%) of total responses (n=29) were ever engaged in GF funding requests at the level of country dialogues. Countries, which included youth in their priority funding lacked youth representation in their CCMs. In countries without either youth representation or youth engagement within CCMs, youth were restricted to national youth councils, and working with other stakeholders to reduce harassment and ensure support to people living with HIV, for instance. However, across the board, it was a challenge to engage with youth living with tuberculosis and malaria.
In all of the above, there were demands for capacity building for advocacy and for resource mobilization for funding support for country dialogues and consultations. The 2023 audit of CCMs by the Office of the Inspector General (OIG) mentioned that the Global Fund had enabled communities to participate and be consulted in decision-making by making special provisions in the funding request tools under the Covid-19 Response Mechanism. However, more needs to be done as per an external survey featured in the GF Report.
RISE survey in 2023:
- Communities outside of CCMs want to be consulted more and need support for this as 66% felt they were not being consulted at all or too little and only 28% were satisfied with the funding.
- Further, only 47% of CCM Civil Society members had participated in Principal Recipient selection, grant making or oversight activities.
- More worryingly, the RISE Survey, 2023 revealed that 50% of key populations experienced discrimination and 43% experienced intimidation whilst on the CCMs.
Given that the 52 Endline Assessments also showed that while the majority (81%) of 52 CCMs reported a good gender balance, ensuring representation of people living with diseases is still far from being attained. The Global Fund acknowledged that a lot of work remains to be done to make CCMs more inclusive. Support from development partners also needs to be amplified so that representative voices are not left isolated. The last is significant as data shows that WHO was represented in a whopping 88% and multi-lateral and bilateral partners in 91% of the 110 CCMs under the IPF.
However, is the Global Fund calling upon its allies to do more to correct what it cannot fix? During the CCM ESI pilot study, among two priority areas, only 22 and 27 of the 93 CCMs chose “supporting CCM composition review and updating processes” and “supporting civil society in preparing and engaging in the election process”. When CCMs themselves do not view these as a major priority, to what extent external influence will help push this agenda is moot.
Conclusion
The Global Fund is alive to the reality that there is lack of effectual engagement of the government with civil society and communities and this has been covered by Aidspan. The Global Fund can establish how governments could undertake such engagement but it also needs to use its political leverage to advocate with the governments to undertake this transformative change. The Global Fund has reiterated that there is a need to establish how communities and CCM principles of democracy and ethics remain within shifting global health priorities, which pose a danger that government-led health governance may get postponed as a near-future objective. And yet, one of the key questions posed to the current Strategy Committee of the Global Fund Board in March 2024 was, “How much should we encourage CCMs to focus on Government–led Health Sector Governance if there are concerns about putting communities at the center?” This question indicates that government control of the CCM has become the real non-negotiable, a legacy of the Global Fund’s own making. Reversing course will take some doing.
