Final Report
Partnership Forum
7th & 8th July 2004
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1. Introduction
2. Key recommendations
2.1 Recognizing the Fund's achievements
2.2 Round Five and continued financing of new projects
2.3 Resource mobilisation
2.4 Country coordinating mechanisms (CCMs)
2.5 Scope of Global Fund financing, round-based funding and the fit of the Global Fund into the overall architecture of health financing
2.6 Measuring performance
2.7 Capacity building and technical support
2.8 Flow of funds, Principal Recipients and the role of Local Fund Agents
2.9 Communications
3. Other suggestions
3.1 Private sector
3.2 Commodities
3.3 Principal Recipients
3.4 Scope of CCMs / Proposals
3.5 Debt Conversion
4. The Partnership Forum process
1. Introduction
The Global Fund on AIDS, Tuberculosis and Malaria (“the Global Fund”) convened its first biennial Partnership Forum in Bangkok on the 7th and 8th of July 2004. The Partnership Forum meets every two years to give a broad range of global stakeholders an opportunity to provide feedback about Global Fund performance and to make recommendations to improve the Fund’s effectiveness. While the Partnership Forum is mandated by the Global Fund’s constitution, it has no legal decision-making role. Rather, its power lies in the moral authority associated with strong recommendations that emerge from a large, diverse and representative cross-section of stakeholders.
The Partnership Forum brought together over 400 participants from over 95 countries. Most of the participants were directly involved in some way in the Global Fund, coming from project implementers, Principal Recipients and Sub-Recipients (PRs and Sub-PRs), Country Coordinating Mechanisms (CCMs), Fund Board delegations, or donor agencies that support the Fund. Reflecting the Fund’s operating principles and funding patterns, these participants came from a cross-section of government, civil society, private sector and affected community backgrounds. A majority of participants were primarily involved with HIV/AIDS work, while about 40 percent were primarily involved in malaria, tuberculosis or some combination of the three diseases.
A significant minority of participants had little or no direct connection to Global Fund financing or structures, but instead were familiar with the Fund because of their involvement in broader issues of health and development policy and programmes. Such participants came from national parliaments, media, academia, the diplomatic service and independent civil society organizations.
Specialized agencies of the United Nations were also well represented.
In addition to the formal Partnership Forum on July 7th and 8th, two other processes were used to solicit stakeholder views and to generate debate and recommendations: a series of regional meetings convened over the previous six months, and an electronic virtual discussion forum known as PartnersGF. While participants at the Partnership Forum itself built on the ideas and recommendations from these other processes, this report intends to reflect only the conclusions of the Partnership Forum meeting itself.
Formally, the Partnership Forum is constituted to report to and advise the Board of Directors of the Global Fund. As such, most of the recommendations that emerged from the Forum were directed to the Board for its consideration and response. In addition, however, a number of recommendations emerged that are relevant for consideration and action by other bodies, such as the Global Fund Secretariat, the Technical Review Panel (TRP) and governments of countries that benefit from Global Fund support.
An independent consultant, Jeffrey O’Malley, was contracted by the Fund to act as lead facilitator for the Partnership Forum. Although under contract to the Fund, this consultant was given full operational independence to shape the Forum’s agenda; design a facilitation strategy; invite a team of independent and volunteer speakers, facilitators and rapporteurs; and to prepare this report. Every attempt has been made to accurately synthesize and reflect the views of Partnership Forum participants and input from the facilitation and reporting team.
The structure of the Partnership Forum was intended to allow for as full, frank and creative a debate as possible. Participants were divided into four parallel working groups for most of the two days, and while each working group discussed the same broad topics, the facilitation style was intended to allow each group to pursue whatever specific issues were seen as particularly important. Outside of these parallel working groups, one session was dedicated to regional gatherings with a completely open agenda. Final recommendations were discussed and verified in some detail in each working group and in most of the regional sessions, but texts were neither “negotiated” nor formally adopted through voting. While this process inevitably led to a wide variety of recommendations, what is striking is how much consensus emerged around a number of key recommendations.
2. Key recommendations
Except where specifically noted, the recommendations listed in this section of the report reflect the expressed opinions of a very large majority or a consensus of participants at the Partnership Forum. The exact wording of most recommendations has been edited to allow for the merging of overlapping reports from the parallel working groups.
2.1 Recognizing the Fund’s achievements
The Partnership Forum highlighted the substantial progress and success of the Global Fund in a very short time period. Most importantly, participants welcomed the success of the Fund in attracting and investing significant additional resources to fight AIDS, tuberculosis and malaria. Many participants highlighted additional Fund benefits or successes, including: genuine responsiveness to country priorities and strategies; successfully linking life-saving malaria and tuberculosis work to the momentum of the global response to HIV/AIDS; introducing an unusual degree of transparency and consultation into a significant financing mechanism; pragmatically and creatively responding to criticism and crises; and maintaining an emphasis on the involvement of affected communities, as reflected in the recent Board decision to give the Communities Delegate to the Board full voting rights.
The overwhelming celebration of the Fund’s initial successes was tempered by acknowledgement that real impact was yet to be demonstrated at scale and by a series of specific criticisms of Fund performance and processes reflected further below.
Action required: none.
2.2 Round Five and continued financing of new projects
A large majority of delegates called for the Global Fund to launch “Round Five” – its next call for new proposals – at either the Ninth Board meeting in November 2004 or early in 2005. In more detailed discussions:
- Most delegates endorsed the notion that re-financing of successful existing
projects should take priority over new initiatives. Given the strong support
for Round 5, delegates therefore called for increased resource mobilization
(see section 2.3 below).
- A number of delegates familiar with Board-level discussions called for
reconsideration of the Global Fund’s “Comprehensive Funding Policy”
in order to allow new commitments beyond the level of cash deposits in the Fund’s
bank account. There was neither dissent from this view, nor detailed discussion
of its implications.
- Beyond Round 5, there was considerable interest in moving away from a round-based proposal review system (see section 2.5 below) as the only mechanism for distributing funds.
A small minority of delegates, mostly from OECD countries, called into question the need for considerable new funding to be made available in the next twelve months.
Action required:
- Board committee decision regarding Round 5, soon enough to allow possible
announcement at November 2004 Board meeting.
- Board consideration of Comprehensive Funding Policy.
2.3 Resource mobilisation
While there was some debate and disagreement concerning the proportion of global need that should be financed through the Global Fund, as opposed to other sources, the vast majority of delegates expressed concern that the Global Fund was not raising enough money to allow for renewal of successful projects, launching of new rounds, correcting for increasing costs of second-line HIV treatment and other key commodities, and providing long-term, predictable commitments to countries. Specific recommendations included the following:
- In advance of the Ninth Board Meeting and the planned Replenishment
Conference, an appropriate Board committee should consider the immediate financing
gaps for 2005 and develop a short-term strategy that would allow Round 5 to
be launched.
- The Board should develop and make public a long-term and sustainable
resource mobilization strategy built on an analysis of global resource gaps
and needs, the role of the Fund vis-à-vis other financing mechanisms,
an equitable contributions framework linked to each country’s share of
global GDP, and an advocacy strategy focused on “where the money is”:
the Treasury or Ministry of Finance level.
- The Board should accept its own responsibility for fundraising, dedicating
time at each Board Meeting to the subject.
- Most delegates indicated that the Global Fund Secretariat should not itself be responsible for conducting the needed resource gap analysis. Rather, the majority indicated that such analytical work was primarily the responsibility of countries, with global analysis to be carried out by appropriately mandated international technical organizations.
Action required:
- Board committee launch of short-term fundraising as needed to allow
imminent launch of Round 5.
- Board to develop and make public longer-term resource mobilization /
replenishment strategy.
- Board to establish standing agenda item to consider resource mobilization.
- Global Fund Secretariat to work with appropriate partners to ensure
ongoing identification of country- and global-level resource gaps, and appropriate
analysis and consolidation of such data.
- Donor countries should provide additional funding in the short-term to allow Round 5 to be launched, in addition to any longer term pledges that will be linked to the Fund’s replenishment strategy.
2.4 Country coordinating mechanisms (CCMs)
Some of the liveliest discussions at the Partnership Forum concerned the composition
and operation of Country Coordinating Mechanisms (CCMs) and, more specifically,
whether the Global Fund should require that certain principles be respected
or simply recommend that such principles be respected. In all the working groups,
the discussion initially reflected dynamics that had recently been visible at
the most recent Global Fund Board meeting, with civil society participants for
the most part arguing for requirements and representatives of governments in
the South for the most part arguing for recommendations only. Fortunately, the
considerable amount of time allocated to these discussions led to some genuine
breakthroughs that should be urgently considered by the Global Fund’s
Board of Directors.
On the issue of composition of CCMs, two of the four groups made progress by breaking down an “omnibus” recommendation into specific components, discovering that there was a full consensus that quite a number of the specific guidelines should be considered as requirements, including:
- That all CCMs must meaningfully include people living with HIV and people
affected by tuberculosis and/or malaria; and,
- That all CCMs must include representatives from the NGO sector.
Furthermore, these groups reached consensus that CCMs should be required to follow certain operating principles, including:
- That the CCM chair and vice-chair must be from different constituencies
(e.g. government and civil society);
- That CCM Chairs, CCM Vice-Chairs and PRs must be from different entities;
- That CCMs must be subject to strong standards for the management of
conflict of interest, issued by the Global Fund’s Board;
- That CCMs must establish transparent mechanisms for input of all stakeholders
to proposal development and review;
- That CCMs must establish transparent mechanisms for participation of
stakeholders in grant implementation;
- That CCMs and CCM secretariats must be able to benefit from financial
and technical assistance to ensure “good practice” in governance;
and
- That CCMs and CCM secretariats must be able to benefit from clearer operational guidelines to be issued by the Global Fund.
These two working groups agreed that the Global Fund should ensure that the standards above are defined in such a way as to be auditable and, thereafter, that the CCM performance in this regard is audited.
A number of further proposed requirements were put forward by some participants in these two working groups, but no consensus was reached as to whether or not they should indeed be imposed by the Global Fund:
- The establishment of a minimum percentage of civil society and community
representatives on CCMs;
- The mandatory or recommended involvement of the private sector on CCMs;
and,
- The establishment of a system within countries whereby NGOs and community representatives select their own representatives, rather than being selected by the government or another body.
A third working group noted that the overwhelming majority of their participants agreed with the suggestions noted above, but that a small number of delegates did not agree.
The fourth working group proposed a slightly different approach, agreeing on the need for strong operational guidelines to be issued by the Global Fund Secretariat and for auditable standards, and agreeing that it was important to go beyond recommendations to CCMs. In contrast to the other groups, however, the majority of participants in the fourth working group suggested that concurrence with the new guidelines should be promoted by rewarding high-performing CCMs with incentives, rather than having the guidelines be mandated or required.
Finally, many delegates within all working groups and regional break-outs expressed concern that CCMs do not always adequately include people with a background in malaria and/or tuberculosis (as opposed to HIV/AIDS), and that there was often inadequate attention to the involvement of women. Other constituencies identified by some parties as under-represented included labor, young people and technical partners.
Action required:
- The Global Fund Secretariat should immediately begin developing much
more rigorous and auditable standards for CCMs, paying particular attention
to CCM composition, transparency and inclusion in decision-making, and mitigation
of conflict of interest.
- The Board, perhaps through its Governance and Partnership Committee, should revisit as soon as possible the CCM issues raised by Partnership Forum participants.
2.5 Scope of Global Fund financing, round-based funding and the fit of the Global Fund into the overall architecture of health financing
Two working groups and one of the regional break-out groups considered some combination of the following issues: the scope of Global Fund financing, the strengths and drawbacks of the current proposal / round system and the fit of the Global Fund into the overall architecture of health financing for developing countries. In addition, all of the working groups had at least some discussion about the implications for the Global Fund of donor harmonization efforts in general, and for HIV/AIDS in particular, the UNAIDS promotion of the “Three Ones” (that is, promotion for each country of one agreed HIV/AIDS Action Framework that provides the basis for coordinating the work of all partners; one National AIDS Coordinating Authority, with a broad-based multi-sectoral mandate; and one agreed country-level Monitoring and Evaluation System).
While the Partnership Forum did not develop and agree upon firm recommendations with regard to these issues, it clearly called on the Global Fund Board to launch a process of reflection and consultation that could lead to future policy changes. Specific issues flagged for consideration in such a process included the following:
- There was a strong consensus amongst Partnership Forum participants that
the Global Fund should remain focused on AIDS, tuberculosis and malaria.
More specifically, however, a significant minority of participants strongly
felt that there are short-comings in the Fund’s current “responsive”
approach to funding (i.e. the current lack of guidelines on proposal content
and strategy). Some delegates felt that there should be stronger guidelines
to influence the development of proposals (for example, drawing attention
to specific concerns such as a focus on poverty, a responsiveness to gender
inequity, or the desirability of stronger links between HIV and TB responses).
A small minority called for more than guidelines, suggesting that the Fund
should be quite proscriptive in indicating a preference for certain types
of strategies or interventions deemed to be strategic.
- There is a desire to examine the strengths and weaknesses of the current
“round and project proposal” system. Many participants believe
that the Global Fund should consider a very different kind of project proposal
system, with less attention to the detail of proposed activities, and more
attention to how the proposal fills gaps, leverages additional resources
(from both national and international sources), and contributes to national
strategic objectives. Such an approach would also require more attention
within proposals to an overall analysis of the “resource gap”,
additionality strategies and the proposed systems within countries to subsequently
re-allocate resources to specific projects or activities. The existing “round
and project proposal” practice is perceived to have some important
advantages, however, including its contribution to resource mobilization,
advocacy and inclusion of different constituencies.
- The “Three Ones” initiative was broadly welcomed by people
involved in HIV/AIDS work, and there was some call from malaria and tuberculosis
constituencies for similar initiatives to improve harmonization and coordination
within affected countries.
- A number of participants suggested that the Fund could make a significant
additional contribution to countries if it was able to make longer term
commitments of support (for example, over a period of ten years), even if
such commitments were to remain conditional upon performance. This would
provide yet another value to the Fund, in comparison with shorter-term bilateral
financing.
- Despite the general support for the issues noted above, concern was expressed from a number of civil society and private sector representatives that any review and update of the Global Fund’s project proposal and round system should lead to increasing opportunities for NGO and private sector participation (including through stand-alone proposals), rather than decreased involvement under the guise of “supporting national plans”.
Action required:
- Global Fund Board and representatives of the Technical Review Panel
to review strengths and weaknesses of the current proposal and round system,
and the length of funding commitments, in 2005 (i.e. after a successful
launch of Round 5 using the current system).
- Request from the Global Fund that Roll Back Malaria, Stop TB and other relevant stakeholders consider lessons being learned from the current UNAIDS “Three Ones” campaign, with a view to considering similar initiatives in their fields.
2.6 Measuring performance
The Partnership Forum recognized the importance of strengthening monitoring and evaluation (M & E) systems both as part of overall health system strengthening and to enable effective assessment of impact and performance-based funding. Delegates felt that the Global Fund should ensure that countries have access to consistent guidance on indicator development and on M & E system strengthening in relation to the three diseases and consistent with the UNAIDS principle of the “Three Ones” (see Section 2.5 above).
In addition to the importance of disease-related impact measurements, several of the working groups recommended that appropriate targets and indicators be identified and promoted that will reflect whether or not Global Fund financing is indeed contributing to (or undermining) broader health system strengthening, as well as to the achievement of the Millennium Development Goals.
Suggestions were also made regarding the inclusion of indicators to measure gender specific / sex disaggregated outcomes; community involvement; community empowerment; client satisfaction; civil society involvement; poverty reduction; progress against stigma and discrimination; and integration of efforts against multiple diseases.
Two important caveats emerged in response to the discussions described above. Many delegates expressed skepticism about the quality of data currently being collected and reported, and the implications of this for the Global Fund’s claim to be “performance-based”. Further, a number of delegates expressed concern about overloading M & E systems with specific requirements driven by particular agendas, rather than focusing on gathering high-quality data on a small number of particularly strategic indicators.
Action required:
- A clear majority of the delegates would like the Board to ensure that grant recipients be required to gather additional data that measures additionality, the contribution of the Global Fund to health system strengthening, and the contribution of the Global Fund to the Millennium Development Goals.
2.7 Capacity building and technical support
All the working groups and most of the regional break-out sessions discussed the inter-linked issues of front-line delivery capacity, intermediary support capacity (that is, the ability of PRs and sub-recipients to appropriately channel funds, provide technical support, promote quality control, and ensure M & E), and south-south and international technical support. There was a broad consensus that these issues had not necessarily received enough attention in proposal design and approval to date, and delegates welcomed the recent decision of the Global Fund Board to establish a committee to focus on these issues.
While recognizing that the Global Fund is already willing to fund technical support and capacity-building costs within proposals, most delegates expressed their belief that the Global Fund Secretariat should more actively promote attention to these issues in proposal design and that the TRP should assess attention to technical support and capacity-building as part of its proposal assessment process. That said, a clear majority of the delegates did not believe that the Fund should itself be developing a technical support capacity. There is a clear consensus that the preferred technical support solution is to finance in-country providers through Global Fund proposals.
To the extent to which supplementary support was also required, the Partnership Forum urged much more attention to strategic partnerships with agencies with the mandate and/or experience to provide such technical support, not only within the UN family but also amongst NGO and private sector providers, and through partnerships whereby bilateral agencies co-funded and/or co-provided technical assistance. Some suggested that it would often be difficult to include such costs within standard country proposals, and that consideration should be given to a special, limited, funding window for such activities.
Participants noted that when assessing capacity-building needs, attention is needed to the capacity of governments to work with civil society and the private sector (and not just the inverse); to the capacity-building needs of the CCM to provide proper governance and oversight; and to the capacity of PRs and/or sub-recipients themselves to be technical support providers and/or to play a quality control function.
Action required:
- The Global Fund committee examining technical assistance issues should note the Partnership Forum consensus in support of in-country and south-south technical support whenever possible, the near consensus that the Global Fund should not itself become a provider of technical assistance, and the strong belief that international technical support (when needed) should be sourced from a wide variety of providers (based on suitability and cost), not just from the UN family. The committee should also consider opening a special funding window for international technical support costs.
2.8 Flow of funds, Principal Recipients and the role of Local Fund Agents
A clear majority of participants in all the working groups expressed concern about the role and performance of Local Fund Agents (LFAs), who were not sufficiently represented at the Partnership Forum. Particular concerns cited included the lack of a permanent LFA presence within some countries and subsequent delays and misunderstandings; poor LFA communication with the CCM; poor LFA communication with PRs; and LFA under-performance in ensuring that funds were moved quickly through the country system to the front-line of service providers.
The value of having an NGO-based PR to support other NGOs and CBOs as part of a country project was noted by many participants. Delegates cited the Secretariat’s own recently published report documenting the efficacy of NGO-based PRs compared to government-based PRs, as well as sharing additional supporting anecdotes. A minority of delegates, mostly from Southern governments, expressed concern that the Fund should not impose such a model, even if it is sensible in many settings.
The Secretariat’s recent efforts to develop “early warning systems” for PR non-performance were warmly welcomed. Delegates suggested that when such an early warning system is triggered, CCMs and the Fund should automatically be required to reconsider the choice of PR.
Action required:
- The Global Fund Board and Secretariat should quickly take note of
the extent of dissatisfaction with current LFAs, strongly issuing clarifying
guidance to LFAs in the short-term, and considering more profound changes
to the LFA system.
- The Secretariat’s ongoing flexibility and pragmatism in dealing with PR issues was welcomed; the points noted above should be considered in future actions.
2.9 Communications
There was broad agreement that the Fund should be commended for its culture of transparency but that significant improvements are rapidly needed in two areas:
- Making consultation documents, guidelines and official documents available
in all six official UN languages as quickly and widely as possible.
- Improving and clarifying the communication channels amongst the Secretariat, CCMs, PRs, sub-recipients, and LFAs, with particular attention to promoting “multi-directional” communication that would overcome existing bottlenecks (for example, at the moment LFA reports typically are not shared with CCM members). Some delegates also noted that the Fund’s reliance on web-based communications caused problems for many key stakeholders, especially at a community level.
Action required:
- Global Fund Secretariat to amend its communication plans and its guidance to CCMs, LFAs and PRs, accordingly.
3. Other suggestions
A number of other suggestions and recommendations emerged from specific discussions at the Partnership Forum that are noted below for the record. Unlike the key recommendations listed above, the suggestions listed below did not benefit from in-depth discussion nor did they emerge in parallel in multiple working groups and break-out sessions. As such, no specific action required is specified.
3.1 Private sector
One working group expressed its support for the public / private partnership approach of the Global Fund, while noting that in most countries a true partnership mechanism with the private sector has yet to be devised. This group called on the Global Fund’s stakeholders to increase their attention to this issue, including calling for proposed strategies from the private sector itself.
3.2 Commodities
One regional break-out group noted that the Global Fund is not yet promoting adequate interaction with existing commodity procurement mechanisms at global and country levels. There was a consensus within the group that the Global Fund should, at a minimum, be aggressively pursuing such collaboration. A minority of participants in the group felt that the Fund itself should develop a role in global procurement, but there was a great deal of opposition to this proposal from some other delegates.
Another regional break-out group emphasized that a number of the key commodities that make up a large part of the cost of existing Global Fund projects are likely to soon increase in price due to changing trade laws and patent issues. The Fund was encouraged to proactively examine the likelihood of key commodity price increases and to develop an appropriate strategy to minimize the impact of such changes.
3.3 Principal Recipients
While endorsing strongly the importance of developing in-country support systems, one working group of the Partnership Forum suggested that in certain scenarios, designating a multilateral or bilateral agency as a temporary PR of last resort might be a legitimate preference of a CCM.
3.4 Scope of CCMs / Proposals
One of the regional sessions proposed that the Fund should more actively promote both sub-national CCMs and proposals (in large and/or diverse countries) and supra-national or regional CCMs and proposals.
3.5 Debt Conversion
One of the working groups suggested that the Fund should include attention to debt swaps / debt conversion within its proposed new resource mobilization strategy.
4. The Partnership Forum process
Participant reaction to the Partnership Forum was solicited from anonymous evaluation forms distributed at the end of both days of the Forum and supplemented by informal and anecdotal feedback. About 30 percent of the participants, from a cross-section of backgrounds, provided some formal feedback.
Delegates overwhelmingly welcomed the initiative of the Global Fund to organize the Partnership Forum, welcomed the opportunity to both express their views and to hear others, and encouraged other funding agencies to consider similar processes in the future.
Delegates believed that they clearly understand the objectives of the Partnership Forum and that they had enough background to usefully contribute. Many participants suggested, however, that they would have preferred to receive better organized summary documentation about the Forum, from previous regional meetings and so on, in advance of the meeting (or at least in advance of the presentations).
Participants were overwhelmingly satisfied with the opening plenary, with many respondents only listing “most useful” aspects of the Forum and/or noting that “nothing was not useful”. There was particular praise for the country perspectives, although a number of respondents found some of these presentations too long or unfocused. The second-most cited “most useful” aspect was Tommy Thompson’s presentation, although this presentation was also cited by a number of respondents as “least useful”.
Respondents largely found the introductory presentations in parallel sessions on the first day to be useful, although many noted that these presentations were too long and/or presented too quickly.
About three-quarters found facilitation to be at least “good”, with many of these saying it was “very good” or “excellent”. However, another 25 percent or so on the first day found facilitation to be “fair” or “poor”. Complaints included that facilitation was too directive (most often) or not directive enough (once). There were particular complaints about facilitators talking or sharing their own opinions after every intervention and appearing to call too much on “known” individuals. A few respondents felt that the facilitators were being too “pro-Fund” while some others felt they were being too “pro-NGO” (as in not drawing out government perspectives). Many useful suggestions were received regarding facilitation, including more time in small groups (frequently suggested), taking time for identifying a few compelling recommendations, “pushing people towards solutions”, and ensuring that facilitation was more guided and/or more prioritized.
A number of participants noted in the second-day evaluation that both the presentations and facilitation had been improved from day one to day two, expressing their appreciation that first-day feedback had been taken into account by the facilitation team. Overall satisfaction with facilitation and the format of the Forum was very high by the end of the second day.
People were largely satisfied by the quality of discussions, although frustrated by the lack of time and the large number of people. There were particular frustrations from some well-informed participants that others seemed to lack basic information about the Fund.
The regional break-out “open sessions” were seen as very positive by about 75 percent of participants (citing opportunities for unstructured discussion, regional perspectives, etc), but as not at all useful by a significant minority.
The interpreters received particular praise.
Amongst many other comments, the most notable concerned the relative under-representation of key governmental representatives.
* The Partnership Forum Steering Committee wishes to thank Jeffrey O’Malley,
the Partnership Forum lead facilitator, for drafting this report.
Annex 1-4 can be found in the complete report (PDF - 480 Kb)
