Structured Abstract
| Document Title: | Tracking the Global Fund in four countries. An interim report. Draft 8th October 2003 |
| Institution: | London School of Hygiene and Tropical Medicine |
| Authors: | Ruairi Brugha, Gill Walt, Mary Starling, Martine Donoghue |
| Study commissioned by: | Development Cooperation Ireland (DCI), the Danish Agency for Development Assistance (DANIDA), the United Kingdom Department for International Development (DFID), and the Netherlands Directorate-General for International Cooperation (DGIS) |
| Objectives: |
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| Methods: | Descriptive qualitative study in four countries (Mozambique, Tanzania, Uganda, Zambia) over a 4-5 week period in each country, from late April to early July 2003. Criteria for choice of countries : significant levels of disease burden for HIV/AIDS, TB and malaria; ministries of health (MoH) in all four countries have indicated support for the study; the countries all have instigated sector wide approaches (SWAps) and are hosts to other global health initiatives; and bilateral donors funding the study have had long-standing partnerships with national governments. Combines semi-structured interviews (an average of 34 interviews was conducted in each country) with a broad range of stakeholders in each country (senior government policy makers, representatives of bilateral and multilateral agencies, faith-based groups, non-governmental organisations (NGOs) and community groups); non-participant observation of CCM and other meetings of country partners; and a review of relevant documentation, which will be included in a final report. |
| Results: | The main findings are presented and organised according to four main issues (see original Summary of findings):
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Summary of findings
1. Application Processes
Decision to apply- Government-led - the motivation was the possibility of additional funds.
- Countries submitted round 1 proposals because of fear of "the well going dry" (i.e. GF resources might run out).
- Governments were either optimistic, or reckoned they would learn from the experience.
- Donors tended to be more sceptical.
- A six week deadline meant hurried and intensive proposal preparation.
- Some countries used it as opportunity to develop/adapt existing disease control policies and strategies.
- There were different approaches in different countries - from centrally controlled to participative.
- Within-country technical support was used.
- Lessons learned from round 1 meant that in some cases there was better use of working groups, covering the three diseases and cross cutting systems issues. One country attempted to be more inclusive.
- There was more use of external technical assistance - while useful, this may have detracted from lesson-learning and development of proposals that fitted with the country context.
- These were brief but not sufficiently clear in round 1.
- They were more detailed by round 3 in response to country requests for better guidance and GF's need for more information; but were now more time-consuming to complete.
- There were mixed views about content - with more concerns around process.
- There was difficulty in getting detailed feedback from TRP in round 1 - the source of these communication problems (between Geneva and countries, or within countries) was unclear.
- Requests for clarification from the TRP were difficult to manage and required frequent communication between CCMs and Geneva.
- A wide range of stakeholders were involved working with MoH and national AIDS council (NAC)8: different line ministries, NGOs, civil society, faith-based and private sector organisations.
- Applications were successful (in rounds 1 and/or 2) in all four countries. In some countries, it promoted country ownership, in others trust-building between constituencies.
- The process stimulated planning across three priority diseases.
- The process catalysed policy and strategy development.
- Transaction costs were low for governments - mainly covered by donors, though these resources needed to be solicited.
- Opportunity costs were generally perceived as high but it was difficult to identify the exact nature of the other activities which were delayed or omitted due to a focus on the GF. Views may have been influenced by the outcome of applications.
- Timely financial and material support from different donors facilitated proposal preparation.
- A balance between inclusivity and keeping the CCM 'lean' was difficult to achieve - it was helped by working groups.
- Can proposal formats be more flexible, to allow countries to submit existing, costed systems-strengthening and disease-control plans?
2. Country Coordination Mechanisms
Setting up CCMs- They were established in a hurry as a GF condition.· NAC was not seen as an ideal vehicle - being disease specific - but it provided the closest fit.
- Selection of representatives from the different constituencies had to be done quickly - it was controlled by government in three of the four countries.
- Self-selection by constituencies was seen as a positive development in one country.
- Selection of representatives was easier where there were existing umbrella bodies and networks.
- There was difficulty in finding suitable and acceptable representatives from NGO and private sector.
- Constituencies represented on CCMs were broadly similar across countries.
- CCMs expanded in response to demands for additional constituency representatives.
- Balance - some felt that CCMs were skewed towards government and HIV/AIDS.
- High level political representation on CCMs provided credibility within government.
- CCM constituency composition was representative, but within-constituency consultation and feedback were poor due to: lack of time, lack of resources, lack of consultation mechanisms, poor communication, irregular attendance at meetings, ideological differences within constituencies, delegating attendance to junior staff, and work overload.
- There was a rapid turnover of individuals representing key constituencies, e.g. line ministries.
- Delayed notice of meetings and distribution of documents impaired participation.
- Participation of the different constituencies was considered good in some countries and less so in others, where government was seen as dominating meetings.
- Country representation at the global level (Geneva) would benefit from stronger regional networking across recipient countries.
- Internal communication problems such as a lack of notice of meetings and last minute access to documentation compromised CCM members ability to attend and participate in CCM discussions.
- External communication problems with the GF secretariat were reported as initially poor but improved over time - difficulties were ascribed to GF secretariat constraints and communication constraints in countries.
- There was uncertainty about where communication breakdowns occurred, whether between GF and countries, or within countries.
- Where constituencies are not already formally organised into umbrella groups or networks, they may welcome support and assistance to form and strengthen representative bodies.
- Where it occurred, the self-selection of constituency representatives onto the CCM appeared to be preferred by constituency membership.
- There is some evidence of a recognised need and will to tackle some of the obstacles to representation - for example, one donor had offered to fund the strengthening of an NGO communication infrastructure.
- How to rationalise planning processes and meetings to reduce workload on key decision makers (an issue that also arose under 'systems fit')?
- What are the avoidable causes of delayed or lack of communication between CCM members?
- What are the avoidable barriers to effective participation on CCMs, whilerecognising the need for government-led and owned processes?
- What lesson-learning has there been between recipient countries and how well is regional representation working at the global level?
3. Post Approval Structures and Processes
CCM function and fit- There was uncertainty around the function of the CCM after proposals were submitted and grant agreements signed, notably around CCM relationship with Principal Recipients (PRs).
- There was a lack of clarity about the 'fit' between the CCM and NAC in some countries - the NAC was sometimes seen as having greater legitimacy with tensions in some countries over the control and use of resources for HIV/AIDS control.
- There were concerns about the capacity of some proposed / selected PRs to carry out their functions.
- There was reluctance or concern about taking on the role of PR or subrecipient in disbursing funds to multiple NGOs, many with limited capacity.
- There were mixed views about the need for the LFAs but little contention over the companies selected.
- There were concerns among LFAs about some implementing agencies abilities to fulfil reporting and financial requirements.
- Initial expectations of rapid access to resources had not been met because of slow disbursement of funds to countries.
- People expected that disbursement within countries would also be slow.
- There was and continues to be a need for timely dissemination of guidelines on evolving GF structures and processes to CCM members.
- Countries may adopt different models or approaches to embedding CCMs within existing and evolving partnership structures - CCM legitimacy may grow over time as its function becomes clearer.
- Building capacity of PRs and sub-recipients to fulfil roles and responsibilities is an urgent need, which donors and other country partners may wish to address.
- How can CCMs, established as a condition for the GF, be integrated into country policy and partnership organisational structures, notably around HIV/AIDS?
- How best can countries and GF manage raised expectations of rapid funding if disbursement to and within countries is slower than anticipated?
- What are the advantages / disadvantages of different PR models (single or divided along constituency lines)?
- What will be the consequences if PRs are unable to meet milestones for disbursement?
- Will there be adverse consequences for other programmes and activities if senior MoH managers are diverted to manage GF-specific activities?
4. Systems Fit
Global Fund and country systems- Perceived positive features of the Global Fund:
- a country- led process that gives countries more autonomy.
- promotes public private partnerships, involving NGOs, civil society and the private for-profit sector.
- can be used to fill funding gaps
- Perceived negative features:
- too disease focused and might also divert attention from other health priorities.
- could undermine systems and systems strengthening.
- might mean setting up parallel funding, reporting, monitoring and evaluation systems.
- There was confusion around whether or not GF funds could be channelled through the SWAp - only some respondents were aware that this was now permissible.
- There were concerns that GF funds might not be additional.
There was a range of new global health initiatives (GHIs) around HIV/AIDS arriving in all four countries, e.g. World Bank's MAP programme, and the Clinton Foundation (the latter present in two of the study countries). The potential concerns and features were:
- A burden for governments having to engage in parallel negotiations with different global health initiatives (GHIs).
- A lack of lesson learning across GHIs.
- New global initiatives start being prescriptive and gradually learn to adapt to country contexts.
- All new money is generally welcomed by governments, where systems are resource-starved.
- Government capacity needs to grow to cope with multiple international financing initiatives.
5. Challenges to implementation
Management and disbursement- There would be low capacity, especially among small NGOs, for meeting GF requirements for fund management - including quarterly reporting.
- There was a 'crisis of expectation' and suspicion within constituencies because of slow disbursement of funds. This needed to be managed.
- The criteria for ARV access were not clear - would AIDS activists, rural dwellers, the poor, and women benefit?
- There were concerns around lack of capacity of health systems to deliver ARVs, leakage of ARVs into the private sector, and lack of sustainability of drug supply.
- Absorption capacity (ability to spend well) was not high among some government bodies and some NGOs.
- There was a culture of ineffective spending among some organisations - too many workshops were held and too many guidelines produced.
- There is a need to target spending towards those who are doing service delivery.
- There was a lack of adequate numbers of staff for service delivery, due to staff attrition from AIDS; and low salaried government staff leaving for better paid NGO and donor jobs.
- Building health worker capacity, especially for ARV delivery, would take time.
