Behind the Global Fund's particularly utilitarian definition of CCMs ("Country Coordinating Mechanism") lies a very complex reality.
Indeed, the CCM concept is a radical shift from the traditional "donor/beneficiary" relationship. The anthropological concept of a "gift" provides insight into the origins of the unresolved tensions that generally exist between donor and recipient (Henkel and Stirrat, 1997).
The Global Fund is a pioneer institution that presents itself as a partnership, and aims to let countries decide where and how best to combat the three diseases. The CCM is the governance body that coordinates all stakeholders - including people living with the diseases - to develop programs designed by and for the country.
The organigram below (Fig. 1) clearly demonstrates the partnership role of CCMs: as an "in-country structure" that represents the Global Fund at country level, a fractal-like Board that reflects the network of relationships that this partnership comprises. The "fractal" effect is further evidenced by the Global Fund’s framework documents (Rules of Procedure, the Board's Operating Procedures, and its Committees, etc.) with those of the CCMs, which have been encouraged to create very similar models in their countries (Committees, Secretariat, call for technical experts and other resource persons, including high-level advisory bodies (National Programs, Ministries, UN bodies, technical and financial partners, etc.).
An essential but transient vision
Since the model was conceived it has inspired many development professionals, who were happy to finally let go of the classic post-colonial approach and its basic assumption that "developing countries" could not "succeed" without the (technical, financial, even socio-economic) help of the so-called "developed" world; the latter having also provided the definition of "success".
Unfortunately, in the collective consciousness of all stakeholders, this partnership approach has recently been overshadowed by an "us" and "them" mentality of "The Global Fund requires... ", "The Global Fund provides or refuses/removes according to their definition of eligibility... " - a model of coercion, rather than of collaboration based on shared values and expectations, and mutual accountability.
It is nonetheless not uncommon to hear positive opinions and recognition of the innovative nature of this partnership approach from stakeholders around the world.
"The CCM has brought about positive change in the health landscape in our country. Now ministers and donors have to sit together with activists and people living with the diseases and take account of their voices."
This clearly contradicts the view of some critics of the model, who regard CCMs as artificial, costly, cumbersome entities that embody the blatant hypocrisy of the developed world, which hides behind misleading concepts such as “national ownership” and “democratic multi-sectorality”, and that provide little or no return on investment.
Although it is true that few (if any) CCMs have been able to fully apply the guidelines of the model, not to mention that they have partially failed to do so, it is also true that the economic context in recent years has forced them to "do more with less ", which does not make success any easier.
For example, with a few notable exceptions (the Grant Management Solutions GMS project (2007-2018) funded by USAID, the GIZ Backup Initiative, Expertise France, some Global Fund TA assignments), technical assistance to build capacity around management, governance and change management has been much less common on CCM agendas than technical support provided to program implementers (i.e. in relation to the Global Fund, PRs and SRs, Ministries and National Programs, supply chains, and indeed civil society organizations).
However, there is an undisputed consensus that strengthening leadership and governance within CCMs is crucial to achieve ambitious impact goals. Without this, CCMs will not only be ineffective but risk stirring a hornet's nest of conflicting interests, power games, and even open or hidden conflicts.
There are certainly potential constraints to increased performance of CCMs: parliamentary procedures that do not fit well with local customs and practices; a heavy workload for volunteers, who often wear multiple professional hats, that can lead to a disastrous overload of work; budget and infrastructure issues that can stop things running smoothly; a lack of availability and/or understanding of technical data, which undermines the quality of decisions; a lack of integration of the CCM in the national health system beyond Global Fund programs, which creates frustration and limits its credibility and therefore influence.
High membership turnover, often without formal mechanisms to maintain and share institutional memory, weakens efforts to maintain momentum, and makes it impossible to step up the fight. The lack of legal status and/or institutional integration often limits recognition by the sector as a "serious" body beyond "Global Fund business".
In addition, "capacity building" and performance evaluations that are imposed - and not necessarily well designed, planned or executed - by external partners do not always encourage the desired self-determination and ownership. Indeed, it is difficult to establish appropriate performance indicators (KPIs) when it comes to evaluating a voluntary committee whose composition is sometimes so heterogeneous in terms of capacity, experience or social status that a consistent and common mode of operation can be a major challenge.
Do potential catalysts exist?
For some time, certain partners (notably international cooperation agencies) have expressed growing (and understandable) frustration about the inability of CCMs to sustain the positive results of capacity building interventions, often carried out multiple times.
However, it is not a hopeless situation. It may be necessary though to recognize that we tend to suffer from a case of "always doing the same thing hoping for a different outcome."
Let's start with changing behavior…
"Change will not come if we wait for some other person or some other time. We are the ones we've been waiting for. We are the change that we seek." - Barack Obama
It seems to me that this is key to the inevitable overhaul of CCM performance improvement approaches. Let's be optimistic: Change is not easy, as Peter Senge, world-famous author of The Fifth Discipline, said: "People don't resist change; they resist being changed."
In this sense, it is necessary to systematically strengthen institutional structures (membership, committees, dedicated Secretariat), procedures (rules of procedure, ToR, governance manual) and policies (CCM policy with minimum requirements and standards, code of conduct) based on behavioral factors of the collective culture, which is a vital element of successful organizational change.
The new Code of Ethical Conduct demonstrates the Global Fund's strong commitment to aligning CCMs with other actors with the goal of establishing shared standards and values of ethical conduct and serving the common vision of a world free of AIDS, tuberculosis and malaria, and the collective mission to end the epidemics by 2030. This Code is not just another tool, it represents a change of direction and emphasizes compliance as a way to enable performance, rather than compliance as a synonym of performance.
The code has been introduced to CCMs jointly by the CCM Hub and the Ethics team, and aims to strengthen them from the inside, according to principles of the CCM Evolution project and based on CCMs developing their own Theory of Change.
In particular, it is hoped that CCMs will broaden the scope of one of their key functions - strategic oversight - beyond Global Fund grants and implementing partners, so as to have a comprehensive overview of the "health landscape" and to track the trajectory of diseases and progress towards subsequent impact objectives. Ideally, any General Assembly should follow these trajectories at the national level, asking the crucial question, "are we on the right track?" and coordinating the next steps depending on the answer.
We therefore hope that the majority of CCMs will seize the opportunity to fully play their role as key players in achieving the ultimate goals of ending the epidemics and achieving the SDGs by 2030.
Clare Gibson is a United Kingdom-based consultant who specializes in supporting institutional change and capacity building.