Structured Abstract
| Document Title: | The Early Steps of The Global Fund in Cambodia. January 2002 - October 2003 |
| Institution: | Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium |
| Authors: | Katharina Kober & Wim Van Damme |
| Study funded by: | Directorate General Development Cooperation, Belgium. |
| Objectives: |
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| Methods: | Main field research conducted in Cambodia from 1 to 20 July 2003, complemented by a further one-week research visit in November 2003. The time covered by the study stretches from the Global Fund's first call for proposals on 31 January 2002 until the end of October 2003. The focus of this report is on the pre-implementation phase, on the initial processes around proposal preparation and creation of the Global Fund mechanisms in the country. The methods used were qualitative: 22 semi-constructed interviews with staff from the senior levels of the MoH, from bilateral and multilateral agencies as well as from international and local NGOs, representing their constituencies at the CCM or otherwise involved in any of the processes related to the Global Fund in Cambodia; review of documents related to the Global Fund in-country processes, such as minutes of meetings, written communication between different parties, guidelines, plans and other written tools; review of documents related to the organisation of the Cambodian health system in general. A draft summary of the opinions expressed in the interviews was fed back to all stakeholders for their comments. The findings were submitted to academic peer review. As a consequence of this review process, the original coverage period was extended by three months to 31 October 2003. |
| Results: | The main findings are presented and organised according to the following main headings (see original Summary and Conclusions):
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Summary
Results in brief
The Global Fund was launched in January 2002 to make available and manage large amounts of additional funds for the fight against AIDS, TB and malaria and rapidly disburse these to the countries in greatest need. It describes itself as a "financial instrument not an implementing entity" and established a number of key principles such as efficient and transparent disbursement mechanisms, support of programmes reflecting national ownership and strengthening health systems, a focus on performance based disbursement, and an emphasis on partnerships between governments, NGOs and the private sector.This report presents the findings of a case study of the early steps of the Global Fund in Cambodia from January 2002 until the end of October 2003. During three weeks in July, and one week in November 2003, we conducted 22 semi-structured interviews with representatives of the government, the civil society, bilateral and multilateral agencies and international NGOs who were members of the CCM or in other ways involved in the Global Fund in Cambodia. Furthermore we reviewed relevant documents in the country as well as from the Global Fund website and incorporated the stakeholders' feedback on our draft summary of interviews. The aim of this study was to report the stakeholders' different views and experiences regarding the pre-implementation phase of the Global Fund in the country and identify lessons that may be useful for the further successful development of the Global Fund both in Cambodia and in other countries.
In 1991 Cambodia emerged from decades of violent political turmoil. After the Paris Peace Agreements in October 1991 the UN Peacekeeping Forces (UNTAC) moved in and Cambodia was put under UN administration until the first general elections in 1993. The Khmer Rouge, who infamously ruled the country from 1975 to 1979, had destroyed the health infrastructure and killed almost all Cambodian medical doctors. A high number of foreign experts became thus involved in the task of rebuilding the health system. Today, bilateral and multilateral donors and aid agencies continue to have a high presence in the Cambodian health system. Still, the MoH has been gradually strengthened and the latest health sector strategic plan 2003 - 2007 puts a strong emphasis on its further institutional strengthening. The public health system is underfunded, and the very high share of out-of-pocket expenditure is mainly spent in the unregulated private-for-profit sector. Cambodia's health status continues to be poor relative to other countries in the region. TB, malaria and HIV/AIDS, each of which has a designated National Center, are very significant health problems.
Cambodia has established a fully fledged Global Fund architecture as suggested by the Global Fund guidelines. In each of the Global Fund's three calls for proposals, in January 2002, July 2002 and March 2003, Cambodia submitted one country coordinated proposal. In the first round the HIV/AIDS component, in the second round all three disease components were approved for a total 2-year budget of over US$24 million.
Our findings show that the Global Fund fuelled a lively exchange of opinions and active participation of many different actors, held together by the overall desire to make the Global Fund work in Cambodia. While we tried to interview representatives of a broad range of in-country stakeholders, we could not get the views of all people involved in the Global Fund in Cambodia. What we present in our findings are opinions and viewpoints of individuals as expressed in the interviews. All opinions documented in this study do, of course, depend on the angle from which the particular respondents are looking at the Global Fund and can, while valid, only present part of the picture. This may be influenced by an 'expatriate bias' due to the high number of expatriates involved in the Global Fund in Cambodia, voicing their opinions more easily than their Cambodian colleagues. A tendency to highlight exclusively the aspects of the Global Fund in Cambodia they perceived as negative while taking the undeniable positive developments for granted, was noticeable. Still, many of the findings and conclusions of this case study are not exclusive to Cambodia but concur with those of other studies of the Global Fund in various countries.
Apart from bringing very much needed resources for the fight against AIDS, TB and malaria, the Global Fund has undoubtedly initiated a new and promising dynamic in Cambodia. For the first time the MoH is channelling money to NGOs and, equally for the first time, actors from the civil society are represented in a decision-making committee together with the Cambodian government. The Global Fund's open and participatory overall approach, and the readiness of the representatives of the Global Fund secretariat to listen, take seriously and react to local concerns were very much appreciated in Cambodia.
Two major observations, both related to the disparities between the Global Fund's discourse at international level and the reality on the ground, emerge from our findings. The first is related to the intention of the Global Fund to build on existing country structures rather than to create new and additional ones. Our findings show that the Global Fund in its initial phase in Cambodia is perceived as an initiative that requires the creation of entirely new institutions and the adaptation of old ones. Both are very human resource intensive and time-consuming processes. The second observation concerns the Global Fund's principle that its programmes strengthen existing health systems and take into account local priorities. In Cambodia the Global Fund is perceived more as a new vertical programme whose focus on the three diseases excludes proposals that cannot be earmarked under AIDS, TB or malaria, even when they are based on nationally defined and widely agreed priorities for the health system.
Other major findings reflect what has been documented in other countries, too. Thus, proposal preparation time was generally perceived as too short, hence affecting the quality of the proposal preparation activities, such as the creation of the new Global Fund structures and the review process of new proposals. Particularly the role of the CCM regarding proposal approval and support to potential new applicants suffered from the restricted time frame. It was thought that by starting the proposal preparation before the formal call for proposals was issued these problems could be avoided.
In the absence of clear guidelines from the Global Fund, many details of the preparation process and also of fundamental issues such as the CCM's mandate need to be negotiated on the ground, a time-consuming process and potentially problematic when disbursement of funds and implementation of programmes start before the CCM's responsibilities have been agreed upon. It may slow down progress at every stage of the Global Fund processes.
Also the importance of a shared language for the participation of civil society has been remarked on in other studies. In Cambodia, as long as the language of all meetings and all written communication is English, effective inclusion of those who are not sufficiently conversant in English is not possible. A simultaneous translation service at all CCM meetings and written translations of the main Global Fund guidelines and documents would facilitate open debates and informed participatory decision-making, increase transparency, and foster the sense of ownership of the civil society representatives. Participation and transparency are important features of the Global Fund and to assure them it is important to give all stakeholders an equal chance to formulate their different opinions in a constructive manner.
A particular concern in Cambodia was how to make the wider structures of the MoH and the health system benefit from the considerable amount of capacity building that is being provided to the Principal Recipient, a group of seven staff from the MoH. Now that the disbursements for Round One have started it is not likely that the momentum of the Global Fund in Cambodia will soon slow down. Quarterly reporting by Sub-Recipients and Principal Recipient, along with other ongoing issues such as the finalisation of the procurement plan and the concurrent preparation for the Round Two programmes, will mean high workloads for MoH as well as expatriate staff involved in the CCM. This will make it difficult to gain 'breathing space' in order to develop strategies for making the health system profit from the big amount of technical input into the GF structures.
The CCM in Cambodia, pivotal for the Global Fund and a real innovative structure, is currently the topic of a study commissioned by the Global Fund itself. While the focus of our study was not exclusively on the CCM, several important findings relate to it. First, the CCM in Cambodia is indeed a new and potentially very important participatory mechanism. For the first time, representatives of a wide range of actors, including the budding civil society, not only sit around one table but also have been given the mandate to make decisions.
The CCM during proposal preparation. Time consuming commitment in CCM activities, such as dissemination of information relating to the Global Fund, facilitation for "national stakeholders wishing to scale-up their activities", and "oversee[ing] the monitoring and implementation of the proposals" is difficult for some constituencies without extra funding. This may result in either a situation where members representing only those constituencies who have enough extra capacities shoulder these responsibilities of the CCM, or where the CCM limits its role and functions only on a minimal scale, thus forgoing the opportunity of becoming an important partnership mechanism.
As long as it is not clear what role the CCM should and can play regarding assistance and support for civil society organisations interested in applying for Global Fund funding, potential new applicants may be discouraged from preparing a proposal. This may result in a '(pre) selection bias' in the sense that mainly proposals from experienced NGOs or ministries continuing with proven interventions enter and pass the review process. The proposals of small and less experienced NGOs, who lack the money for an external consultant, may have more innovative ideas but not pass the review process because they are in need of substantial technical improvement.
The CCM during implementation. For further proposal preparation processes, but particularly with regard to the implementation phase of the Global Fund programmes it will be important for the CCM to clarify its roles and responsibilities. Continued quality support of the implementing actors during programme implementation has been identified by the World Bank as a major factor for success of its MAP1 Program for Africa. And, according to the Cambodian Monitoring and Evaluation Plan for the first round of the Global Fund, the CCM will have an extensive and important role during the implementation phase, not least the provision of support to various other bodies. This poses big challenges for the CCM, the stakeholder constituencies it represents, and the Global Fund. In order to have a realistic discussion of and decision about the future roles and functions of the CCM, the constituencies represented in it need to take a clear stance about their possibilities and intentions of budgeting for this kind of work. Considering the expanding role of the CCM, the Global Fund itself, too, might find it appropriate to consider making resources available for its functioning.
This study documents that the early steps of the Global Fund in Cambodia present a mixed picture. Its promise to bring important additional resources for the fight against AIDS, TB and malaria is being confirmed. Its principle of involving a wide range of stakeholders has been applied during the pre-implementation stage in Cambodia and is enhancing commitment and a sense of ownership among many actors. Yet, the Global Fund's desire to use existing systems and to avoid a heavy administrative workload has been realised to a lesser extent. This may need extra attention. However, it has to be kept in mind that the Global Fund is a dynamic initiative, moving forward with a considerable pace, and that therefore the present study can be no more than a spotlight on one part of this process. It can, like other studies that have been conducted of the Global Fund in countries where implementation has not yet started, point out some early lessons and issues which may need to be followed-up during the implementation of the Global Fund programmes.
