A consultation workshop in Addis Ababa, Ethiopia on country coordinating mechanisms (CCMs) provided an opportunity for CCM members from 15 countries to discuss the challenges facing CCMs and to put forward suggestions for addressing the challenges.
The workshop, which was held on 5-8 September 2017, was one of five regional consultations, the others being held in Siem Reap, Cambodia; Kiev, Ukraine; Abidjan, Côte d’Ivoire; and Panama City, Panama. In this issue of GFO, we report on two of the consultations: this one in Addis Ababa and the one in Abidjan (see GFO article).
The Addis Ababa consultation was organized by the Global Fund’s CCM Hub, the International HIV/AIDS Alliance, and GIZ / BACKUP Health (on behalf of the German Federal Ministry for Economic Cooperation and Development and the Swiss Agency for Development and Cooperation). The workshop brought together participants from 14 Anglophone countries from West, Eastern, and Southern Africa, plus Afghanistan. Delegations were composed of three CCM representatives, one from the government; one from civil society organizations (CSOs) and key populations; and one from the CCM’s Oversight Committee. The workshop was also attended by other relevant stakeholders, such as Global Fund Board members representing the Eastern and Southern African constituency as well as communities; representatives of regional civil society networks, and bi- and multi-lateral partners of the Global Fund; and other civil society representatives, including young people and watchdog organizations. Aidspan was represented by its Executive Director, Ida Hakizinka.
The objectives of the consultation were described as follows:
- to review and discuss the current “standard” model for CCMs, including how to improve the model;
- to discuss a differentiated model for CCMs, including how to modify the standard model to adapt to the various country contexts; and
- to provide a platform for a learning exchange, especially on CCM governance, the CCM eligibility requirements regarding oversight, and civil society/key population engagement.
Participants were told that there is a need to review and evolve CCMs in tandem with the new Global Fund Strategy 2017-2022.
The first two days of the workshop were about how to improve the current CCM model, as well as how CCMs could evolve. The last two days involved a learning exchange on a variety of topics related to CCMs; participants had an opportunity during this part to present good practices.
The proposed CCM Code of Conduct (COC) was introduced at a plenary on Day 1. It was discussed in one of the small group sessions (see below).
Most of Day 1 was taken up by small group discussions on five topics: CCM function and CCM secretariat; national program coordination and linkages; CCM engagement and composition; CCM oversight; and ethics, including the proposed COC and conflict of interest (COI). The following is a summary of the outcomes from the small group discussions:
CCM functioning and CCM secretariat
Participants said that membership selection criteria should be strengthened to facilitate the selection of members with the capacity to both represent their constituents and engage at the CCM level.
Participants recommended that the capacity of CCM secretariat staff be strengthened through (a) targeted training on CCM issues and general Global Fund issues; and (b) the development of additional guidelines on the role and functioning of the secretariat. Participants said that the CCM secretariats should be supported to ensure the timely distribution of documents to CCM members and committees.
Participants said that the CCM performance evaluation system should allow for individual CCM members to be evaluated, including by their respective constituencies.
Participants called for the transition and orientation process on the CCM to be strengthened. Participants said that it was vital for new members to have at least a working knowledge of the Global Fund processes at country level and at the level of the Global Fund Secretariat. Participants said that an orientation should be conducted whenever new members join the CCM.
One issue identified by participants was that many principal recipients (PRs) do not meaningfully involve CCMs, particularly with respect to the interactions between the PR and local fund agents (LFAs). Participants suggested that operational procedures concerning the engagement between the PR and LFA be revised.
Participants indicated that current funding for the operations of the CCM, which comes almost entirely from the Global Fund, was inadequate. They said that CCMs should look for other sources of funding, including from national budgets.
National program coordination and linkages
Participants recommended that the mandate of CCMs be modified to focus more on a wider health sector role.
Enhancing the participation of ministries of health (MOHs) in CCM processes is a critical step in improving linkages between the Global Fund and other health sector AIDS, TB and malaria programs, participants stated. For this reason, they said, the active participation of MOHs in CCMs is vital and should be reinforced through revised CCM guidelines and other means.
Participants recommended that the capacity of CCM secretariats be enhanced to enable the secretariats to coordinate with other national health sector committees and technical working groups (TWGs). They cited as Zambia’s CCM secretariat as an example of where this has been done effectively. Along the same lines, participants recommended that CCMs seek representation in other national health sector committees and TWGs.
Participants said that CCMs should work towards being officially part of the national government. Participating in national budgeting processes was identified as a good starting point, as it would provide CCMs with an opportunity to advocate for increased funding for the three diseases. Being formally part of the government would enhance the financial sustainability of CCMs and would give CCMs the status of a national level coordinating body.
CCM engagement and composition
Participants recommended that CCMs consider including representation from the national parliament. They pointed out that this has been done in Nigeria and Zimbabwe and that, as a result, CCMs and Global Fund programs in these countries have received increased support.
Participants said that CCM power imbalances – i.e. where representatives of government and development partners wield more power than CSOs and key populations – need to be addressed.
Participants recommended that a comprehensive needs assessment be conducted of all CCM members, and that a capacity building plan be developed to address the needs.
Currently, interaction between CCM members and their constituencies is limited, participants said. This is sometimes due to the limited capacity of the members and sometimes to a lack of resources (and sometimes both). Regarding key populations, they said, the limitations are compounded by existing legal and policy environments. One suggested remedy was to explore the use of low-cost technologies to enhance communications.
Workshop participants identified several measures to enhance CCM oversight, including the following: (a) providing training and capacity building for CCM members; (b) using consultants to assist oversight committees; and (c) increasing the budget for the oversight committees.
Participants said that there is a need to improve communications on oversight matters because of the many stakeholders involved in oversight. They called for the development of a communications guideline and policy specific to oversight. Precisely because there are many players involved in oversight, participants stated that there is a need to clarify the roles of the various players. Participants said that it is important to avoid bypassing CCMs when country teams and LFAs work with PRs. They recommended that the oversight roles of the CCM, country teams and LFAs be clarified.
Participants said that oversight guidelines based on good practice and evidence should be developed.
Participants called for the establishment of an external “platform” to advise and assist CCMs on the development and review of their oversight strategies, to review oversight findings, to suggest how problem areas could be addressed, and to monitor the implementation of improvement plans. The platform should include stakeholders involved in Global Fund grant oversight, such as country teams, LFAs and PRs, they said.
Ethics, including the CCM Code of Conduct and conflict of interest
With respect to the proposed CCM Code of Conduct (COC), some CCM members and a Global Fund Board member said that there should be more consultation at country level to allow CCMs to provide additional input. Participants suggested that there be a follow-up Board consultation to consider the additional feedback.
Participants were of the opinion that the COC should be flexible enough to accommodate diverse country contexts. They said that some elements of COI policies and procedures – which is a big part of the COC – are not followed in every country because they are not applicable in some countries. Participants stated that the roll-out of the COC should include a compulsory training component because a good understanding of the COC is vital.
Management of COI should go beyond a declaration of conflict during CCM meetings, which is the current practice, participants said. They recommended that the process include mapping of CCM members’ associations with the full network of grant implementation (e.g. PRs, sub-recipients, suppliers).
Participants said that it is impossible to completely avoid conflicts of interest because most people who sit on CCMs have a direct or indirect interest in Global Fund programs. They cited the example of the MOH which is usually a key implementer of grants and, at the same time, is a critical player in developing health policy, and also plays a key role in the deliberations of the CCM. Participants said that the emphasis should be on managing and mitigating the impact of conflicts of interest.
Participants suggested that due diligence be conducted on each CCM member before they are appointed, as a way of avoiding potential conflicts.
One feature of Day 2 was a discussion related to CCM differentiation. As part of its CCM Evolution Project, the Global Fund Secretariat has proposed a differentiated approach to CCM roles and structures. As defined by the Global Fund, the differentiated approach consists of evolving from the status quo where there is one standard model for all countries to having several models based on country size and operational context. Under the proposed approach, country size includes three categories: high impact, small and standard. The operational context consists of two categories: challenging operating environments (COEs) and the countries in transition.
Participants were divided into three small groups based on the categories described above: high impact countries, small countries, and challenging operating environments. However, unlike at the Abidjan consultation, where there was push-back on the proposed differentiated approach (see GFO article), participants did not discuss the merits of the proposed approach. Instead, the discussion centered around ways to improve the effectiveness of CCMs. Some of the suggestions advanced were similar to those that emanated from the small group sessions on Day 1. Below we provide a summary of suggestions that built on, but did not duplicate, earlier ones.
Participants expressed the need to ensure the change process and CCM evolution is sensitive to country contexts, considering all countries have different political, economic and epidemiological status. They said that this will also circumvent “one size fits all” challenges associated with the current CCM model.
(Note that on Day 3 there was discussion on the topic of CCM evolution generally; see below.)
In high-impact countries, there is urgent need to increase the number of staff members in the CCM secretariat, and to strengthen secretariat’s capacity and skill mix, participants said. In addition, participants identified a need to focus on strategies for funding CCM secretariats in high-impact countries. One option is to phase out Global Fund support for CCM operations. Participants said that a gradual process should be implemented to shift CCM support from the Global Fund to countries’ national budgets. Another option is to explore the possibility of co-financing with partners such as PEPFAR.
Participants stated that there is a need to review country team support to grants in high-impact countries.
Vulnerable groups tend to be left behind in high-impact countries, participants said. They called for the development of a key population engagement strategy and guidelines to ensure vulnerable groups are meaningfully engaged.
Participants said that inconsistent participation of CCM members is common in small countries. They suggested that CCM guidelines for small countries should explicitly state the requirements for member participation in CCM activities.
Participants suggested that the CCM evaluation and performance appraisal system be used on an ongoing basis to monitor CCM performance.
Challenging operating environments
The Additional Safeguard Policy (ASP) should include a plan for countries that are under the policy to transition back to “normal” operations, participants said. They suggested that the plan include an in-country capacity building component. Participants said that these same suggestions should apply to countries designated as COE.
Participants suggested that consideration be given to allocating higher operating budgets to CCMs in COEs. In addition, they said CCMs in these countries should have access to increased TA.
In COEs, CCMs need additional guidance on who is included in key populations; on a key populations engagement strategy; on the need for enhanced communications; and on safety and security policies, participants said. As well, they said, enhanced capacity building and training is required for CCMs in COEs. Further, participants suggested that COE countries explore the possibility of providing performance-based compensation for CCM members.
Finally, participants called for greater flexibility concerning the number of PRs required to implement grants.
Day 3 was the start of the second part of the consultation. It featured a session on the expectations and challenges of CCM evolution. Many of the expectations mentioned by participants reflected suggestions they had made in earlier sessions. What was new, however, was that participants identified five requirements for successful CCM evolution:
- scale up dissemination of the Global Fund Strategy 2017-2022;
- develop a comprehensive communication and change management strategy (i.e. developed by the Global Fund Secretariat for countries);
- develop transition and capacity building plans for major shifts;
- ensure appropriate TA is available; and
- engage CCM members fully in the evolution process.
Day 3 included a panel session on sharing lessons learnt and best practices. There were presentations on Rwanda’s experience on integration of the CCM within national health programs; Ethiopia’s experience in preventing COI; Kenya’s experience in CCM oversight; and Liberia’s experience in improving civil society and key population engagement.
Below, we provide a brief summary of two of the presentations.
CCM integration with national health sector: The Rwanda experience
Rwanda has integrated Global Fund grants into the national health sector through an established Health Sector Working Group (HSWG). The HSWG acts as a joint platform for coordinating and monitoring health sector programs. The Rwanda CCM does not have an oversight committee because oversight is performed by the HSWG. Through the platform, all sub-sectors are informed of current programs and available resources; this minimizes duplication and generates efficiency gains.
Ethiopian experience regarding COI
In Ethiopia, the COI policy was not implemented as a standalone policy, but rather as an integral component of the procedures manual. The policy covers potential and perceived conflict, including in the following areas: grant implementation; oversight and review of Global Fund programs; selection of PRs and SRs; and reprogramming of grant funds. The policy covers situations where CCM members and CCM secretariat staff have close friends or relatives who run organizations that are recipients of Global Fund grants or are involved in direct and indirect procurement of goods and services. Other issues covered in the policy are: gifts; the positions of the CCM chair and vice-chair with respect to grant implementation; proper process when a member believes that another member has an undeclared conflict; consequences of failure to declare a conflict; publication of the COI policy; and the need for annual orientation or re-orientation of CCM members on the COI policy.
Most of Day 4 was devoted to small group discussions on concrete actions to improve the engagement of CSOs and key populations; CCM oversight; and CCM governance. Again, many of the points raised overlapped with suggestions from earlier sessions. Below we describe selected new ideas that emerged from the discussion.
CSO and key population engagement
Resources should be allocated specifically for constituency engagement, participants said. They suggested that for every CCM meeting, there should be pre-and post- face-to-face constituency engagement meetings.
Participants identified two populations – people in rural areas, and young people and youth – who are often not represented on CCMs. They suggested that interaction between country teams and the CCM be increased.
Participants said that the presence of women on CCMs does not in itself ensure that gender issues receive sufficient attention. CCMs need to ensure that there are CCM members with the necessary skills to speak to gender issues.
Participants recommended that CCMs explore the possibility of hiring dedicated personnel to support CCM oversight, or seconding government officers to fulfill that role.
Participants said that Global Fund country teams and the CCM oversight committees should review their respective roles and discuss the need for coordination between the two entities.
Participants said that CCMs should have a strategy for dealing with gradually reducing Global Fund support; and a resource mobilization strategy for when Global Fund stops providing support.
In addition, participants called for a conversation on the establishment of CCMs as legal entities.
During a session on TA, participants discussed the impact of the closure of the Grant Management Solutions (GMS) project. GMS was a major provider of TA. Participants were of the opinion that the closure of the GMS project will create an immense TA vacuum and that the other major TA providers may not have the resources to fill the gap.
Inputs from this consultation will be synthesized with those of the other four regional consultations, and reported back to the Board committees tasked with developing a strategy for the evolution of CCMs. The recommendations from the consultations will also be used to review and update key policy documents such as CCM guidelines, the CCM Funding Policy, and the proposed CCM Code of Conduct.
On 30 October, a spokesperson for the CCM Hub provided the following information to Aidspan on the status of the CCM Evolution Project:
The CCM Hub has been conducting CCM Evolution consultations and presenting feedback to the three Board committees. In all, the Hub met with 66 CCMs, representing 63% of all CCMs, in the five regional workshops; received feedback from an additional six CCMs through questionnaires; conducted a desktop review of documents covering 30 countries; and consulted, through questionnaires and face-to-face meetings, with 25 country offices of local fund agents, 17 watchdog or advocacy groups and technical platforms as well as 10 multi- and bi-lateral bodies from a total of 88 countries. The Secretariat has started interviewing board members for their thoughts on how the CCMs should evolve.
The CCM Hub has now begun the challenging process of analyzing the feedback and developing recommendations for the Board to review at its May 2018 meeting. Common themes emerged through all of the consultations, such as a definite need for differentiation. However, aside from preparing to transition and transitioning, the differentiation model may focus on CCM levels of strategic engagement and maturity, not those first envisioned (e.g. high-impact country, COE, small country). Other findings included the positive relationships between strong CCM secretariats and leadership, and CCM functioning; a need for a greater role of CCMs in oversight; a need for CCMs to further link with national governments; and robust constituency engagement.
Over the next few months, the CCM Hub will work on analyzing the information and feedback it received, which will include costing each of the action items and determining the item’s impact and the level of effort needed to achieve it. Once these steps are completed, the Hub will develop various differentiation models or options, which it will then present to the Board.
Once all of the workshop reports have been finalized, they will be publicly distributed.
Rhoda M. Lewa contributed some reporting for this article.