“Country ownership” has been one of the core principles of the Global Fund since it was created in 2002. The Fund’s Framework Document says: “The Global Fund will base its work on programs that reflect national ownership and respect country-led formulation and implementation processes.” The Fund’s Who We Are brochure says: “The Global Fund model is an innovative approach, based on the principle of country ownership.”

But what does “country ownership” mean? For years, this is the way Aidspan has been describing it:

“The Global Fund is country-driven. This means that the Fund does not say, in effect, ‘We will give you a grant if you use it in the way that we instruct.’ Instead, its message is, ‘What will you do if you receive a grant? What results will you achieve? If we believe that you can indeed achieve those results, if we believe that the results represent good value, and if we have enough money, we’ll give you the grant.’ Thus, it is the applicant, not the Fund, who proposes what will be done, and the Fund then decides whether to finance those activities.”

Is this what “country ownership” meant in the past? Does it still mean that today? This article discusses both questions.

What does “country ownership” mean?

The High-Level Panel that reviewed many aspects of the Global Fund in 2011 said:

“The Panel has heard the mantra of ‘country ownership’ invoked to explain and justify almost every aspect of the Global Fund’s business model and decision the institution makes. Yet while ‘country ownership’ is a founding principle highlighted in the Framework Document, there does not appear to be a shared perception – inside or outside the Global Fund – about what the term means in practice.”

The report of the High-Level Panel contains a long discussion of what “country ownership” means or should mean for the Global Fund. The Panel said that within the Global Fund Secretariat, “the constantly reinforced, but hazily defined, ideology of ‘country ownership’ has bred a culture of passivity in grant management.”

The Panel said that a commitment to country ownership does not mean “writing a blank check without communication, follow-up or accountability.” It said that country ownership does not mean “applying such a hands-off approach that grantees struggle with implementation when a proactive approach could help relieve bottlenecks.” In the Panel’s view, country ownership needs to look different from country to country, depending on the ability and willingness of countries to accept and exercise responsibility for Global Fund programmes.

The Panel recommended the Global Fund Board adopt a re-defined statement on country ownership at its November 2011 meeting.

In 2011, the Global Fund produced a Consolidated Transformation Plan (CTP) covering the reforms it was introducing. Large parts of the CTP were informed by the findings and recommendations of the High-Level Panel. The CTP included a project whose objective was “to develop a new definition of ‘country ownership’ in the context of the Global Fund’s risk management framework.”

At a retreat of the Global Fund Board on 29 March 2012, General Manager Gabriel Jaramillo said that this project had not yet been completed. Aidspan is not aware of any work having been done on this project since then. Certainly, no new definition of “country ownership” has been adopted by the Board.

According to a report on the retreat, presented to the Board at its 26^th meeting in May 2012, Board members believed that “country ownership” needed to be maintained and even strengthened.

How “country ownership” has evolved

In truth, “country ownership” was never interpreted as meaning that the Global Fund should “write a blank cheque.” From the outset, limitations were placed on the application of the country ownership principle. One example of this is that the Global Fund required that countries establish multi-sectoral country coordinating mechanisms (CCMs) if they wanted to apply for money. The Fund established minimum requirements which, in theory at least, CCMs had to meet to be eligible for funding.

And almost from the outset, the Fund has used the grant agreement negotiations process to influence the content of programmes supported through Global Fund grants. Some programmes that were in the proposals approved by the Global Fund Board never made it into the signed grants. In addition, the grant agreements impose numerous obligations on principal recipients (PRs). As many PRs can attest, and as Bernard Rivers said in a recent GFO commentary, the grant agreement negotiations “have never been a negotiation between equals; it has essentially been a case of the Secretariat saying “sign it or don’t become a PR.”

More and more, over the years, the Global Fund has used other methods to influence the content of proposals, sometimes by “strongly encouraging,” sometimes by “requiring.” These methods include the following:

• The Global Fund establishes the criteria that the Technical Review Panel (TRP) uses to review proposals.
• Through its comments on individual proposals, the TRP lets applicants know what it expects to see in proposals.
• The Global Fund issues guidelines for proposals for each new funding opportunity.
• Through its decisions, the Global Fund Board often issues guidance about what the Fund wants to see in proposals.
• The Secretariat “promotes” reprogramming of grants, particularly at the time of renewal for Phase 2 (or the “next implementation period” for single-stream-of funding grants).

Let’s look at some examples. The Round 10 TRP review criteria stated that the TRP looks for proposals that, among other things: use interventions that are evidence-based and consistent with international best practices; give priority to populations most affected and at-risk; address issues of human rights and gender equality; and demonstrate how the proposal will contribute to the strengthening of national health systems.

The following extracts from TRP comments on the weaknesses of individual proposals illustrate how the Global Fund influences the content of proposals:

• “Mass media interventions are very expensive for a concentrated epidemic and do not demonstrate good value for money. In order to reach hard to reach populations, targeted BCC interventions are required.”
• “There is no clear strategy to address the fact that 41 percent of HIV infected women are repudiated by their partners. In addition, approaches to ensure gender equality are not adequately described.”
• “Although the HIV prevalence is low among the general population and in high-risk groups where this is measured, the proposal does not focus most of its resources on sex workers and their clients, men who have sex with men, or injection drug users. Rather, the majority of prevention interventions are scattered and untargeted.”

The Round 10 Guidelines for Proposals informed applicants how some Board decisions affected Round 10, as follows:

“The Board decisions have been included as new or revised questions in the Proposal Form and/or the explanatory material in these Guidelines. In particular, the applicant is encouraged to consider:

• ensuring a better targeted response to address how the three diseases affect men, women, boys, and girls in different ways;
• ensuring that activities address the needs of sexual minorities, including men who have sex with men; male, female, and transgender sex workers; and transgender persons;
• including interventions focused on community systems strengthening; and
• including activities that address HIV and Tuberculosis in a collaborative way.”

For several rounds now, the Fund has strongly promoted the use of dual-track financing (DTF) – i.e., the practice of nominating at least one government PR and at least one non-government PR to implement the grants emanating from a proposal. DTF is not a requirement, but it comes pretty close.

In recent years, the Global Fund has been encouraging reprogramming of existing grants to increase their impact. In 2010, for example, the Fund launched a reprogramming campaign focusing specifically on prevention-of-mother-to-child transmission of HIV (PMTCT). The purpose of this reprogramming initiative was to persuade countries to switch from the use of single dose nevirapine to more effective dual or triple ARV therapy to prevent transmission (see GFO article).

During grant renewal, the Global Fund has gone beyond just promoting reprogramming. When the Global Fund Board recently approved Phase 2 funding for a multi-country HIV grant in Latin America and the Caribbean (see GFO article), the funding was conditional on the grant being completely revamped. The Board was acting on the recommendation of the Fund’s Grant Approvals Committee (GAC), which reviews all requests for continued funding. Here is the wording of the condition imposed by the Fund:

“COPRECOS LAC shall revise the overall strategy and activities proposed for Phase 2. The new strategy shall focus its activities on key populations with high risk of HIV infection. COPRECOS LAC should work together with existing key populations networks (such as REDTRASEX and REDLACTRANS), as implementer partners to promote respect for human rights and to reduce stigma and discrimination in the region.

“The PR shall submit to the Global Fund: (a) a plan detailing the capacity building of COPRECOS LAC with clear deadlines for the transfer of responsibilities to COPRECOS LAC within the Phase 2 period; and (b) a revised work plan and budget that reflects the revised strategy for Phase 2.”

In addition, in recent years the Global Fund has become more proactive in terms of trying to influence the funding and programming decisions of national governments.  On at least two occasions in 2013, during the grant renewals process, the Global Fund has promoted the idea of sending high-level inter-agency delegations to countries to advocate for changes to programmes and for government to spend more on these programmes. In the case of the renewal of a TB grant to Ukraine, the Global Fund recommended a joint mission to engage in discussions at the highest political level to push for health system reforms, changes in payment models and development of ambulatory care models for TB control (see GFO article).

Most observers would likely say that the efforts made by the Global Fund to influence the content of proposals and programmes are a good thing. In many cases, the Fund was just responding to advocacy efforts by individuals and organisations that want to see a stronger response to the diseases at country level. But one has to acknowledge that, in the process, the concept of “country ownership” is certainly evolving. Perhaps it will evolve further under the new funding model.

What do you think about the way “country ownership” has evolved? Please use the comment feature below to share your views.