Meeting Report

Increasing Civil Society Impact on the Global Fund to Fight AIDS, Tuberculosis and Malaria
Strategic Options and Deliberations

2
Full text of proposed strategic measures resulting from the meeting
Amsterdam, the Netherlands 57 January 2007

The full report comprises three separate documents: Part 1. Meeting report for the January 2007 gathering in Amsterdam Part 2. Full text of proposed strategic measures resulting from the meeting Part 3. Full text of key policy paper: Civil Society Options Paper on Community Systems Strengthening All three documents are available online at www.icssupport.org and www.icaso.org.

Supported by the three civil society delegations to the Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria: the Communities living with HIV, TB and affected by Malaria; the Developing Country NGOs; and the Developed Country NGOs.

Part 2 Table of Contents

I. II. Acronyms and Abbreviations Full Text of Proposed Strategic Measures

Note: Two additional sections of this report, Part 1 and Part 3, contain relevant supporting material and information. Because they are relatively lengthy, they are presented in separate documents that are also available online at www.icssupport.org and www.icaso.org.

I. Acronyms and Abbreviations ART CCM CSO CSS FBO GFATM FPM LFA NGO PLHA PR PSC SR TB TRP TS VCT antiretroviral treatment Country Coordinating Mechanism civil society organization community systems strengthening faith-based organization Global Fund to Fight AIDS, Tuberculosis and Malaria Fund Portfolio Managers Local Fund Agent non-governmental organization people living with HIV and AIDS Principal Recipient Policy and Strategy Committee (of the GFATM Board) sub-recipient tuberculosis Technical Review Panel Technical Support voluntary counselling and testing

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II. Full Text of Proposed Strategic Measures

Members of the civil society delegations ultimately accepted six strategic recommendations drafted during the Amsterdam meeting. When combined with a previously drafted recommen dation (see Measure 7), they presented seven proposed meas ures to the Policy and Strategy Committee (PSC) for consider ation at its meeting in March 2007. A series of edits followed prior to submission to the PSC. The full, unabridged text of the final proposed measures is presented below. The language was drafted to comply with the rhetorical and structural specifica tions of the PSC and the GFATM Board. It was presented to the PSC as document GF/PSC7/07. The recommendations are designed to increase civil societys meaningful representation in GFATM processes and programs (as summarized in the meeting report) without straying from the mandate and core business of the Fund. i. Lack of sufficient resources to build the capacity of local civil society organizations Civil society organizations typically require financial support to fund capacitybuilding activities that will allow them to take on the roles above effectively and fully, as they often have limited capacity and limited budgets. ii. Dynamics at the country level that prevent meaningful par ticipation by civil society in the design and implementation of programs In many countries, there is a longstanding pattern that the national government is the sole designer and implementer of health programs. This can translate into a reluctance by governments to include or consult adequately with civil society in planning and implementing programs to fight against the three diseases. The following factors can exacerbate this situation: (a) Conflicts of interest: For example, in a number of countries, the Country Coordinating Mechanism (CCM) chair is from the same constituency as the Principal Recipient (PR). This can have the effect of crowding out opportunities for civil society to engage meaningfully in the development and implementation of proposals. (b) Representation on CCMs: National government representatives, often Ministers of Health, chair the majority of CCMs. In addition, other government representatives, as well as donor or multilateral agency representatives, hold the majority of CCM seats. In such an environment, civil society can find it difficult to have its views heard or taken into account in CCMs. 4. This list is valuable but overlooks additional problems and obstacles. For example: i. Government exclusion of critical voices in many countries civil society organizations that focus on accountability of governments are more often excluded from decision making processes. Likewise, civil society organizations comprised of, and/or working with marginalized or vulnerable or excluded groups are often excluded although other, less controversial NonGovernmental Organizations (NGOs) are represented. ii. Unique aspects of the Global Funds business model the Global Funds requirement of public-private partnerships at all levels is a major paradigm shift in development financing. (a) After five years, however, civil society groups still confront significant challenges when responding to Global Fund grant implementation problems. In 

Strategic measures for leveraging civil society and the private sector
A paper developed by the Civil Society constituencies of the Global Fund Board

executive summary
1. Leveraging civil society is necessary in order to fulfill the Global Funds purpose, as stated in the Framework Document: to attract, manage and disburse additional resources through a new public-private partnership that will make a sustainable and significant contribution to the reduction of infections, illness and death, thereby mitigating the impact caused by HIV/AIDS, tuberculosis and malaria in countries in need, and contributing to poverty reduction as part of the Millennium Development Goals. 2. Although civil society is a critically important partner, ensuring the substantive and effective involvement of civil society at all points in the grant life cycle can be extremely difficult. 3. This is due to multiple problems and challenges. The Options Paper on Leveraging Civil Society and the Private Sector (GF/PSC5/05) lists the following obstacles:

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countries without strong, independent civil society movements and without high-level government commitment to fighting the three diseases in an aggressive and inclusive manner, the concept of the Global Fund as a country-driven mechanism has translated on the ground into program development, oversight and implementation that is dominated by national governments, and that minimizes or disregards the concerns, priorities, and expertise of civil society. (b) This problem should be a concern to all partners but to civil society it is an acute concern, as civil society directly represents the interests of people living with and affected by the three diseases the people who suffer most when grant performance suffers. iii. Strong civil society partnership requires more than in clusion Reversing decades of business as usual models for financing development does not happen overnight, or even in five years. It requires, in some cases, favoring and even over-representing the contributions, opinions and analyses of civil society, in order to ensure that partnership is actively sought, rather than reached solely through the shorthand of token representation on decision-making bodies. 5. The Global Fund is generating strategic measures to address the question: How can the Global Fund more effectively tap the potential of civil society and the private sector (businesses and foundations) and help maximize the impact of their contributions, including by enabling their effective engagement and the appropriate recognition of their contributions? 6. Civil society has developed strategic measures that address this question, without straying from the mandate and core business of the Global Fund. 7. The measures are as follows: i. Strongly encourage CCMs to always nominate a govern ment and nongovernment PR: This measure would greatly increase the number of dual-track financing arrangements, and would prioritize strengthening capacity to make dual-track financing arrangements feasible in the future. This measure would increase capacity for grant implementation in country, and expand multisectoral implementation arrangements at the level of the PR. ii. Make funding for Community Systems Strengthening activities the norm: This measure would greatly increase Global Fund funding for Community Systems

Strengthening (CSS) activities, in order to increase the capacity, effectiveness and viability of community organizations delivering essential health services. The value of community organizations in programs to fight the three diseases is self-evident, yet many CCMs do not plan for proposals to include substantial, coherent, well-constructed CSS subcomponents. iii. Ensure access to funding for CCMs: This two-part measure would lift the current two-year funding cap on financial support for CCM activities (where other funding sources have not been found), and would require CCMs receiving financial support to state how NGOs, marginalized groups, Civil Society Organizations (CSOs), People Living With HIV/AIDS (PLHA) organizations and other members of civil society use these resources. iv. Clarify eligibility criteria for nonCCM proposals from coun tries that suppress or have not established partnerships with civil society and NGOs: This measure would address concerns regarding the application and interpretation of existing non-CCM proposal eligibility criteria. v. Increase representation of vulnerable groups on CCMs: This measure would increase the presence of vulnerable groups on CCMs, by adding new guidelines regarding CCM representation. Vulnerable groups are a critical constituency in civil society, and are often excluded and marginalized on CCMs and sometimes within the civil society sector itself. Strengthening their contributions to proposal planning, coordination and program implementation is an important priority. vi. Create a mechanism for receiving and responding to problems regarding grant performance and governance: This measure would address two concerns shared by civil society as well as other stakeholders: 1) the Global Fund has no internally and externally sanctioned chain of command to activate when grant implementation bottlenecks are identified, particularly by civil society and 2) because of multiple grant implementation activities, responding to reports of problems regarding grant implementation often falls through the cracks. 8. The measure proposed in GF/PSC5/05 regarding CCM leadership being selected from different sectoral blocks is supported and is reproduced here. We also support the proposed operational measures regarding the expertise of the Technical Review Panel (TRP) and the definition of civil society; the implementation of these operational measures is linked to the success of several strategic measures described here. 

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9. We expect that the next set of Key Performance Indicators for the Global Fund and the Executive Director, which will be developed after the Global Fund strategy is endorsed by the Board, will also include indicators regarding leveraging civil society.

able effective in-country implementation capacity. The proposal evaluation criteria do list multisectoral involvement in implementation as a component of the TRPs determination of the soundness of approach, but this is stated as just one of nineteen factors that the TRP should look for. 15. Dual-track financing, in which each proposal would specify at least two PRs, with one (or more) governmental PR and one (or more) civil society or private sector PR, is therefore worthy of serious consideration. 16. According to the Global Funds Investing in Impact Mid-Year Results Report 2006, Dual-track financing can increase a countrys financial absorptive capacity and ensure that obstacles in one area do not slow all other activities. 17. The Global Fund has found that civil society PRs generally disburse money faster and perform better than government PRs, although the number of civil society PRs is at present relatively small. Specifically, the Investing in Impact report found that every one of the 27 grants it studied that had a civil society PR was rated A or B1 during the Phase 2 assessment process, whereas only 65% of the 88 grants studied that had governmental PRs were rated A or B1. (The report did note, however, that civil society and governmental PRs often implement in different conditions, adding that because governments often have larger procurement components than civil society, governmental PRs are more likely to have reasons for implementation delays.) 18. The same report stated that Civil society implementers can mobilize communities to help increase the demand for health services. [] Countries must find ways to make the most use of civil society organizations as implementers alongside the essential role of government. 19. The same report found that in Zambia, dual-track financing has proven to be a flexible, efficient and well-coordinated implementation arrangement. It has extended the financial absorptive capacity of the HIV response in the country. The report also found that in Tanzania, dual-track financing has ensured a comprehensive response and improved absorptive capacity.

STRATEGIC MEASURES TO LEVERAGE CIVIL SOCIETY

Measure 1: Strongly encourage CCMs to always nominate a government and non-government PR Opportunity for enabling greater contribution from civil society and the private sector 10. If the Global Fund is to maximize its impact, it should aim to take advantage of all available and effective implementation capacity at the country level, including capacity offered by civil society and the private sector. 11. In many countries, civil society and the private sector have substantial capacity that would enable them to serve as PRs or sub-recipients (SRs). In addition, they often offer unique skills, such as the ability to reach vulnerable or remote populations that the government could have difficulty reaching as effectively. 12. Furthermore, the participation of civil society and the private sector in programs to combat the three diseases helps to build long-term, broad-based country ownership. It also enhances partnership, which is a core Global Fund principle. For example, the Framework Document of the Global Fund states: The Fund will promote partnerships among all relevant players within the country, and across all sectors of society. It will build on existing coordination mechanisms, and promote new and innovative partnerships where none exist and that the Fund will Focus on the creation, development and expansion of government/private/NGO partnerships. 13. Despite the above, civil society and the private sector currently make up a minority of Global Fund PRs. 14. In addition, the Global Fund does not give CCMs much incentive to take optimal advantage of all avail-

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How the measure would work 20. Summary of overall concept: The Global Fund would strongly and routinely encourage the use of dual-track financing, in which each proposal would specify at least two PRs, with one (or more) governmental PR(s) and one (or more) civil society or private sector PR(s). The governmental PR would normally deal primarily with governmental SRs, and the other PR would normally deal primarily with civil society and private sector SRs, although dual-track financing should not in any way exclude collaboration in implementation between sectors. 21. Specifically, the Global Fund would inform CCMs that: Part 1: With effect from Round 8, proposals should normally specify dual-track financing. Part 2: With effect from Round 8, proposals that do not specify dual-track financing must provide a justification for this. Part 3: With effect from Round 8, proposals that do not specify dual-track financing must explain what will be done to develop capacity such that dual-track financing becomes more feasible in the near future, ordinarily by the subsequent Round. Part 4: All grants that have a single PR and that are seriously under-performing may be required to convert to dual-track financing. Part 5: In dual-track grants, PRs/SRs from different sectors are strongly encouraged to support each other. 22. Objectives of the measure: i. To take advantage of the availability of capacity in all domestic sectors in order to increase the chances that grants will be implemented on schedule. ii. To build up sectors that are weak, thereby increasing the number of people who can be provided with services through Global Fund-funded grants. 23. Detailed description of the measure: Part 1: With effect from Round 8, proposals should normally specify dualtrack financing. The proposal form and proposal guidelines would define dual-track financing and would strongly recommend that proposals specify dualtrack financing. 24. Part 2: With effect from Round 8, proposals that do not specify dualtrack financing must provide a justification for this. The proposal form and proposal guidelines would require that proposals that do not specify any civil society

or private sector PR must provide an analysis of the extent to which there are civil society or private sector entities that are capable, with support, of serving as PRs for the activities covered by the proposed grant. If such entities do not exist, or if their capacity is already fully utilized in other activities, this must be clearly explained. If they do exist but the proposal does not specify that they will be made use of, this must be convincingly justified, with the validity of the justification to be assessed by the TRP (see 17, below). The same approach would be taken to proposals that do not specify any governmental PR. 25. Proposals that do not either specify a dual-track financing arrangement or provide a justification, as described above, would be screened out by the Secretariat and not submitted to the TRP. 26. The Board would request that in cases where proposals do not specify dual-track financing, the TRP should take into consideration the validity of the applicants justification for this when the TRP determines whether to recommend the proposal for approval. 27. Part 3: With effect from Round 8, proposals that do not specify dualtrack financing must explain what will be done to develop capacity such that dualtrack financing becomes fea sible in the near future ordinarily by the subsequent Round. The proposal form and proposal guidelines would require that proposals that do not specify dual-track financing must specify what is being done or will be done (via this proposed grant, via other Global Fund grants, or via nonGlobal Fund-funded activities) to develop capacity such that dual-track financing becomes more feasible in the future for the forms of activity specified in this proposal. 28. The proposal guidelines would make it clear that this is not intended to mean that civil society and private sector capacity building must always be given the same priority as capacity building in the governmental sector. The objective is to obtain comparative advantage. For instance, civil society capacity building might be of particular value when grants provide support for certain kinds of community mobilization, psycho-social support, community health worker outreach, home-based care, et cetera. 29. The proposal guidelines would also make clear that a reasonable and justifiable portion of the funds requested in the proposal should be channeled to each PR, and that this apportionment will be assessed by the TRP. 

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30. Part 4: All grants that have a single PR and that are seri ously underperforming may be required to convert to dual track financing. CCMs and PRs would be informed that for grants from all rounds (not just from Round 8 and later) that have a single PR and that are seriously under-performing, the Secretariat may require that the grant be restructured to use dual-track financing. The intent would not be punitive; it would be to maximize the chances of successful and on-target grant implementation. 31. Specifically: i. With single-PR grants that are being reviewed by the Phase 2 Review Panel and that have been or are about to be rated B2 or C, the Phase 2 Review Panel will routinely consider requiring, as a condition precedent for a Phase 2 rating of Conditional Go, that the grant be restructured to use dual-track financing. ii. The Secretariat may also require restructuring to use dual-track financing with seriously under-performing grants that are at other stages in their life-cycle. 32. Part 5: In dualtrack grants, PRs/SRs from different sectors are strongly encouraged to collaborate and support each other. CCMs and PRs would be informed that the objective of dual-track financing is not to enforce rigid separation between governmental, civil society and private sector implementers; it is for the country to make best use of what each has to offer. 33. Therefore, PRs and SRs from different sectors would be strongly encouraged to meet regularly, to share lessons learned, and to provide and share technical support. In addition, PRs from one sector would be encouraged to consider appointing SRs from another sector when that would lead to capacity strengthening and to increased grant effectiveness. Assumptions 34. To support scale-up and broad-based country ownership of Global Fund programs, the Global Fund should take active steps to encourage multisectoral participation in implementation via use of dual-track financing. 35. Explicitly requiring justification for non-dual-track financing will lead to increased awareness at the country level of the importance the Global Fund places on multisectoral participation in grant implementation. This can encourage greater cooperation between government,

civil society and the private sector from the initial stages of proposal design through grant implementation and oversight. 36. Although the extent of multisectoral involvement in implementation will vary according to the country and the capacities of the different sectors, most countries are able to have some level of multisectoral implementation. Therefore, it is reasonable for the Global Fund to expect all of its grants to have some degree of multisectoral implementation arrangements, unless countries can provide solid reasons for not having them. 37. The TRP is well-equipped to properly evaluate the robustness of a justification for pursuing a single-sector approach to implementation. The TRP will not penalize proposals that include legitimate reasons for not using dual-track financing. Such cases might include, for example, countries with weak civil society and private sector capacities. Implications 38. The Secretariat will have to add one or more sections to the proposal form and proposal guidelines. This will create a certain additional burden for those completing the proposal form. 39. The Secretariat will also need to actively communicate these changes to CCMs/PRs and to provide further guidance on how they can be implemented. 40. Some CCMs will elevate the priority given to building country capacity for dual-track financing. 41. Increased numbers of grants with multiple PRs would increase the Secretariats grant management activities, which would have resource implications.

Measure 2: Make funding for community systems strengthening the norm Opportunity to strengthen community systems to deliver services, improve outcomes, and accelerate implementation 42. In the Framework Document, the Global Fund commits to the principle of supporting proposals that: 

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Support the substantial scaling up and increased coverage of proven and effective interventions, which strengthen systems for working: within the health sector; across government departments; and with communities and which focus on the creation, development and expansion of government/private/NGO partnerships. The Global Fund identifies community-level service delivery, robust coordinating mechanisms, and partnerships between the public sector, civil society organizations and NGOs at the local level as key to successful implementation, scale-up, and country-ownership of comprehensive and sustainable HIV/AIDS, tuberculosis, and malaria programs. 43. Despite its commonsense appeal, community systems strengthening (CSS) is a new and somewhat ambiguous term. Paraphrasing the Global Funds definition: i. CSS elements are focused on strengthening community structures and systems for cost-effective and efficient delivery of a basic, coordinated, defined package of HIV, malaria or tuberculosis services at the community level (for example home-based care, prevention outreach, orphan care, training). ii. The Global Fund describes an indicative list of elements within the category of CSS: (a) Community coordination focal points; (b) Training of new community workers for implementing community-based activities; (c) Training of existing NGO workers in a basic package of skills (service delivery and management); (d) Strengthening community organizations planning and basic monitoring systems. 44. According to Centre for AIDS Development, Research and Evaluation (CADRE), one of the best ways to enhance the impact of community organizations responding to the three diseases may be to focus upon partnership building at the local level to enhance coordination between various actors, to strengthen referral networks and information sharing, and to emphasize the integration of various community responses.1 45. These community-level organizations include homebased care organizations, networks of marginalized and
 The Global Fund has arranged ith CAD to assess dierent CSS coordination models including mentoring organizations, clustering arrangements using local government, volunteer coordination models, netork approaches, and seed-unding organizations. This research ill aid urther development o CSS initiatives.

vulnerable populations, support groups, PLHA associations, womens groups, churches, businesses, and other formal and informal entities. 46. The Global Fund has committed to identifying ways to encourage countries to fund CSS via Global Fund grants, and some grants currently include funding CSS activities. However, CSS activities have not been a focus of proposal funding to date. 47. Civil society has unique competencies and comparative advantages in delivering certain aspects of community-level programming such as: community worker training; prevention-, testing-, and treatment-literacy; peer-group and individual psycho-social support; voluntary counselling and testing (VCT) and outreach testing; treatment adherence; nutritional support; and community health worker, home-based, and orphan care. 48. CSOs, NGOs, and Faith-Based Organizations (FBOs) report that funding is one of their biggest organizational challenges (e.g., poor fundraising skills, inadequate funding, inconsistent funding flows, and weak financial systems and controls) followed by shortage of basic goods (e.g., condoms, universal precautions and safety supplies, food packets), lack of transportation, inability to pay salaries or reasonable stipends to community health workers, and lack of time and expertise to do monitoring and evaluation. 49. There is a need for improved funding models to support community-level responses including umbrella/conduit funding organizations and mentoring relationships for small organizations. 50. To coordinate and deliver these vital aspects of comprehensive programs, community organizations must be strengthened, for example, in terms of organizational capacity, implementation training, human resource development and management. How the measure would work 51. Summary of the overall concept: The Global Fund will communicate to all relevant stakeholders that: i. it considers CSS to be key to successful implementation, scale-up, and country-ownership of comprehensive and sustainable HIV/AIDS, tuberculosis, and malaria programs, and

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ii. it will expect increased requests for funding from countries for activities for country- and communitydefined CSS activities, including activities designed to enhance civil society implementation capacity, coordination and referral systems, and public/private partnership agreements that are integrated within the specific disease component(s). Other specific activities could include: (a) building capacity and strengthening civil society program implementation with technical assistance for financial management, program management, and reporting and monitoring activities by CBOs, NGOs, FBOs, and their enabling partners; (b) training and retention measures for communitylevel and organizational staff; (c) strengthening networks, coordination, and partnership at the local level by developing relevant and appropriate civil society and community resources; (d) linking with marginalized and underserved populations such as men having sex with men, sex workers, injecting drug users, migrants, and rural populations; (e) using partnerships to draw on relevant private sector expertise, and to identify and address service gaps, and to improve referral systems and management efforts. 52. From Round 8 onwards, the Global Fund will communicate its expectation that all proposals should normally include sub-components designed to strengthen community systems. This would be reflected in changes to its proposal form and guidelines. 53. The Global Fund would require that applicants who choose not to include activities designed to strengthen community systems in their proposals provide a justification for this choice. 54. Proposals that do not include activities to strengthen community systems, and do not include a justification for excluding those activities, would be screened out by the Secretariat and not submitted to the TRP. 55. The Board would request that in those cases where proposals do not include activities to strengthen community systems but do include a justification for excluding those activities, the TRP take into consideration the validity of the applicants justification for this when the TRP determines whether to recommend the proposal for approval.

56. Objectives of the measure: i. To increase the impact of Global Fund funded proposals, through better leveraging of civil societys comparative advantage to accelerate rollout and scale-up of comprehensive services at the community level. ii. To strengthen the organizational capacity of individual service providers and implementers at the local level, thereby improving delivery of comprehensive prevention, treatment, and care. iii. To increase shared capacity within CSO, NGO, and FBO networks to deliver an integrated and comprehensive package of prevention, treatment, and care/ mitigation services responsive to local needs and conditions. iv. To improve partnerships, communication, and referral systems between local government structures and non-public sectors, which will lead to an increase in the coordination of services. v. To improve systems for monitoring, reporting, and evaluating community systems and to disseminate best practices and promising innovations. 57. Detailed description of the measure: With effect from Round 8, applicants would be expected to include subcomponent(s) in their disease specific proposals that request funding for CSS. 58. CCMs would be expected to include planning for this category in their proposal preparation activities, and the Global Fund would communicate this change through multiple channels, and would refer CCMs to technical materials and other resources to provide more information about CSS activities during the proposal planning and preparation phase. 59. CCMs that do not include CSS sub-components in their disease-specific proposals would be required to justify that decision. If a justification is not included, the proposal would be ineligible. This justification would be considered by the TRP when it assesses the technical soundness of the proposal. 60. The Board would request that in those cases where proposals do not include activities to strengthen community systems but do include a justification for excluding those activities, the TRP take into consideration the validity of the applicants justification for this when the TRP determines whether to recommend the proposal for approval. 

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Assumptions 61. Donor money cannot be well spent if large amounts of funding do not filter down to the organizations and entities that directly interact with vulnerable and affected communities. 62. Universal access to a comprehensive program of prevention, treatment and care cannot be realized unless capacity is expanded, enhanced, and coordinated at the local level. 63. Explicitly encouraging recipients to seek funding for CSS will lead to increased awareness of the importance the Global Fund places on community-level service delivery and on civil societys participation in program implementation. 64. Implementation of this new measure would result in advance preparation and planning by CCMs to request funding for CSS activities. Although CSS activities are already eligible for funding by the Global Fund, this emphasis on CSS will lead to increased demand for CSS funding. 65. Stakeholders will work to overcome the ongoing challenges of building networking, coordination, partnership, and monitoring systems that facilitate rather than complicate CSS. Implications 66. The Secretariat will need to revise the proposal form and guidelines, as appropriate, to encourage CSS-related funding requests. 67. The Secretariat will need to communicate this change to countries and partners and provide guidance and facilitate the provision of technical support during the proposal and implementation process, as is consistent with its mandate. 68. The Global Fund will need to asses whether the TRP has sufficient expertise to evaluate proposals containing CSS sub components, as well as the implementation capacity of recipients. The TRP may need additional guidance on what the evaluation criteria for review of a separate CSS component would be. Likewise, CCMs and PRs may need additional guidance on setting acceptable targets for CSS activities.

69. Increased focus on CSS might result in more requests to the CCM at country level for small grants, requiring some adjustments in the ways CCMs allocate funding.

Measure 3: Ensure, where needed, that financial support is available for CCM activities, and that civil society has access to those resources Opportunity to increase civil societys effectiveness on CCMs, and the effectiveness of CCMs overall 70. Putting the principle of substantive partnership inherent in the CCM model into action has been difficult. For civil society it has been difficult to become stakeholders with accountability to a constituency, and with power at the table of the CCM. 71. Ensuring civil society representatives are shaping and contributing to CCM activities is an important part of successful grant implementation and accountability, in particular in countries where civil society experiences repression and exclusion, in countries without a history of civil society partnerships, and/or where grant implementation is facing serious obstacles. 72. The 10th Board Meeting approved the following measure: The Board requests the Secretariat to work closely : with partners (multi/bilateral partners, private sector) to facilitate and coordinate the provision of resources to support CCM secretariat functioning. In countries where partner support for CCMs is not available, the Board approves the use of grant funds to provide CCM support, provided that funding is limited to two-years and meets the terms and conditions set out in Part 2 (para.16) of GF/B10/7. 73. In some countries, development partners have stepped forward to fund CCM support activities, making Global Fund resources unnecessary. 74. There are no requirements currently that the resources be used for certain activities, such as efforts to increase the effectiveness of civil society representation. Civil society groups, in particular marginalized groups, have reported that they have not been able to draw upon those resources to increase their capacity and strengthen their participation in CCMs.

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75. Continued access to resources to support CCM activities, and ensuring civil society has access to those resources, are important elements of strong civil society engagement, and by extension, stronger CCMs and better grant performance. 76. The Secretariat reports that the transaction costs associated with requests for these funds are very high, especially when compared with the small amounts of money in question. How the measure would work 77. Summary of overall concept: The Global Fund would revise the current CCM funding requirements to permit CCMs to request a maximum amount of funding each year for up to five years, if other funders have not been identified. This request would be integrated into the proposal request form. 78. At the same time, CCMs would be required to describe how civil society (among other sectors) plans to use these resources. The CCM would also be required to report on those activities; these reports would be subject to verification by the Local Fund Agent (LFA). 79. Objectives of the measure: i. To ensure, when other resources are not available, that the activities related to the functioning of CCMs are supported. ii. To increase the effective and informed participation by civil society representatives on the CCM. iii. To ensure that civil society has access to funding for CCM support activities. iv. To decrease the transaction costs for CCMs and the Secretariat. 80. Detailed description of the measure: The Global Fund should communicate to CCMs that it is changing the current CCM funding support guidelines and the reporting requirements for recipients of CCM support funds. 81. CCMs should be able to request up to a maximum annual amount of funding for CCM support activities, when there is no other funding available. This request would be made as part of a proposal. 82. Simultaneously, the Global Fund will require CCMs to include in their submission of costed plans for use of

these resources and specific information about how civil society will use these resources. If this requirement is not met, the request for financial support for CCM activities will not be considered. 83. In its periodic reports on use of these funds, CCMs would include reporting on the CCM support activities executed by civil society. Assumptions 84. Challenges preventing the meaningful participation by civil society in CCMs can be addressed in part through additional, ongoing funding for CCM support. 85. Financing for CCM support has been helpful in increasing the effectiveness and capacity of CCMs. 86. When partners provide the bulk of CCM financing, it can lead to their domination of the CCMs agenda and processes. Implications 87. There will be an increase in the amount of resources in Global Fund grants committed to direct support of CCMs. 88. CCMs will be required to complete additional tracking and reporting regarding civil society activities. 89. The Secretariat will have to communicate this new policy and reporting expectation to CCMs. 90. LFAs would continue to verify reports on CCM use of funding beyond two years. 91. The high transaction costs both for CCMs and for the Secretariat for small sums of money would be lessened but not eliminated.

Measure 4: Clarify eligibility criteria for non-CCM proposals from countries that suppress or have not established partnerships with civil society and NGOs Opportunity for increasing eligible non-CCM proposals targeting marginalized groups 

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92. Virtually all Global Fund grants have been made to countries whose proposals were endorsed and submitted by CCMs. In particular cases, non-CCM proposals are currently eligible to be reviewed by the TRP. 93. After six funding rounds, an extremely small number of non-CCM proposals have been screened in by the Secretariat, reviewed by the TRP and approved for funding by the Board. 94. The Secretariat is focused on strengthening CCMs and considers the non-CCM proposal window for eligibility to be extremely narrow. Consequently, the bar for eligibility of non-CCM proposals has been set very high, and the Secretariat interpretation of the eligibility criteria has been conservative. 95. Although many CCMs are functioning well, and are good examples of multisectoral partnership, some CCMs are not currently functioning well and are not good examples of partnership. 96. Three criteria currently define the eligibility of nonCCM proposals in countries where CCMs exist: i. countries without legitimate governments; ii. countries in conflict, facing natural disasters, or in complex emergency situations; or iii. countries that suppress or have not established partnership with civil society and NGOs (including a country in which the CCM has failed or refused to consider a proposal for inclusion in the CCMs consolidated proposal.) 97. There are established examples in some countries of suppression of some civil society groups and some NGOs, particularly those responding to HIV/AIDS. 98. Civil society anticipated that a greater number of eligible non-CCM proposals would have been submitted to the Global Fund, in particular proposals that target vulnerable groups and rely on interventions that are at present marginalized by governments, under criteria (iii) above. How the measure would work 99. Summary of the overall concept: From Round 8 onwards, the Global Fund will apply the following technical guidance to the existing criterion (iii) regarding the eligibility of non-CCM proposals:

i. Applicants who demonstrate that an approach to the CCM for inclusion of their proposed activities in a CCM proposal is likely to result in abuse, physical harm/ persecution, or criminalization towards them or their associates, are not required to show they have first attempted to seek CCM review of their proposal. 100. Objectives of the measure: i. To ensure that the letter and the spirit of non-CCM proposal eligibility criteria guides future funding Rounds. ii. To communicate clearly to civil society applying under criteria (iii) what explanation and context is and is not expected of them. iii. To ensure a Secretariat and partner focus on making CCMs work does not inadvertently restrict a window of Global Fund eligibility agreed upon by all stakeholders when the Global Fund was founded. 101. Detailed description of the measure: With effect from Round 8 onwards, the Global Fund will amend its proposal form and proposal guidelines to include a new additional explanation to the eligibility criterion (iii) for nonCCM proposals in countries where CCMs exist. These clarifications will be publicly communicated as soon as possible by the Secretariat and partner organizations and governments to potential applicants. 102. The new notation will include the following clarification: The Global Fund will not require that nonCCM ap plicants first seek CCM review of their proposal in cases where nonCCM applicants can demonstrate that an approach to the CCM for inclusion of their proposed activities in a CCM pro posal is likely to result in abuse, physical harm/persecution, or criminalization towards them or their associates. 103. In some cases, insisting that applicants first seek out review and/or rejection by the CCM could have serious negative consequences. These possible consequences could dissuade applicants from submitting potentially technically sound, lifesaving non-CCM proposals. 104. The Global Fund will clearly explain the criteria concerning non-CCM proposals as well as how these criteria are being applied by the Secretariat. The Global Fund should actively encourage the submissions of non-CCM proposals from countries that meet the criteria.

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Assumptions 105. The current situation, where very few eligible nonCCM proposals are being submitted, is not due to the fact that non-CCM proposals are unimportant or irrelevant. 106. The fact that very few non-CCM proposals are reviewed each Round by the TRP could mean that an important component of the architecture of the Global Fund, developed when the Global Fund was created, has not yet been fully operationalized. 107. Ambiguity regarding how to prepare an eligible nonCCM proposal under criteria (iii) has not been helpful, particularly for those potential beneficiaries in countries that suppress or have not established partnerships with civil society. 108. Not all CCMs are functioning well; while those CCMs improve, civil society would benefit from particular non-CCM proposals in the interim. 109. The Global Fund and partners can strengthen CCMs at the same time that the submission of eligible nonCCM proposals increases. 110. The Secretariat has the capacity to robustly assess the likelihood of potential harm to ensure the proper application of this measure. Implications 111. The number of eligible non-CCM proposals screened in by the Secretariat and reviewed by the TRP will increase, particularly in countries where civil society and NGOs are suppressed or are not in partnership with government. 112. The Secretariat will have to increase its communications regarding non-CCM proposal, developing written materials and other tools that use clear, straightforward language about eligibility criteria. 113. If applicants assert that an approach to the CCM would pose harm, the Secretariat would have to develop standards and processes for assuring that these assertions are accurate. Depending on the number of nonCCM proposals submitted under this criteria, there may be significant resource and transaction cost implications for the Secretariat.

Measure 5: Increasing the involvement of vulnerable populations on CCMs Opportunity to ensure vulnerable populations are involved in proposal development and proposal implementation oversight 114. The Global Fund recommends that all countries strive to include representatives from the following groups in their CCMs: academic/educational sector; government; NGOs/CBOs; people living with HIV/AIDS, tuberculosis and/or malaria; private sector; religious/ faith-based organizations; multilateral and bilateral development partners in-country. 115. According to the Framework Document, the Global Fund is supposed to i. Give due priority to the most affected countries and communities, ii. Aim to eliminate stigmatization of and discrimination against those infected and affected by HIV/AIDS, especially for women, children and vulnerable groups and iii. Strengthen the participation of communities and people, particularly those infected and directly affected by the three diseases. 116. CCMs have implemented several Global Fund requirements and recommendations regarding civil society inclusion and representation, along with minimum standards regarding governance and transparency. 117. For example, the Global Fund recommends that 40% of CCM membership be composed of civil society representatives, and requires that CCMs show representation of people living with and/or affected by the three diseases. 118. By the end of 2005, 67% of CCMs had complied with the recommendation that at least 40% of CCM members come from non-governmental sectors, and 71% of CCMs reported and documented that its membership included people living with or affected by the diseases. However, participation of people living with and/or affected by the diseases is in many cases limited only to one person on the CCM.

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119. Vulnerable populations as such, which may or may not include people living with and/or affected by the diseases are often not represented at all. 120. The Global Fund is an established funder of programs reaching vulnerable populations. Many of the barriers to effective participation by vulnerable groups stem from the harmful stigma and discrimination against these populations, as well as people living with HIV/AIDS. How the measure would work 121. Summary of the overall concept: The Global Fund would inform CCMs as soon as possible that the current recommendation that 40% of CCM membership comprise civil society representatives be modified to include an additional recommendation that among those 40%, there should be representatives of vulnerable groups, as is established by the specific country context. 122. From Round 8 onward, the proposal form and proposal guidelines would direct the CCM to describe how it is implementing this recommendation. The time of Phase 2 renewals would also be used as an opportunity to request that CCMs describe how they are implementing this recommendation. 123. Objectives of the measure: i. To ensure the contributions of vulnerable groups in program development and implementation are incorporated into the work of CCMs. ii. To ensure that CCMs are truly inclusive, rather than being inclusive of only some members of civil society. 124. Detailed description of the measure: As soon as possible, the Global Fund would communicate to CCMs and partners that from Round 8 onwards, and from the time of the start of Phase 2 renewals in March 2008, the Global Fund would recommend that CCMs show how they are incorporating representatives of vulnerable populations. 125. The objective of this requirement is not to complicate matters for or increase the burden on CCMs but ultimately to increase the impact of Global Fund-funded grants, by increasing the involvement of communities that are often marginalized and excluded on CCMs.

Assumptions 126. That people living with HIV and those from vulnerable populations want to represent a constituency as a part of a CCM. 127. That people from vulnerable populations have the resources to undergo democratic and transparent nomination and selection processes to identify representatives. 128. Requiring direct involvement on the CCM will help challenge stigma and exclusion experienced by many people living with HIV and vulnerable populations, and will increase the effectiveness of the CCM. Implications 129. Civil society would have to work together with other stakeholders to devise mechanisms for representation in countries where particular vulnerable groups could actually be at legal risk and/or risk of potential harm by participating in a CCM.

Measure 6: Introduce a mechanism for raising problems regarding grant performance and governance Opportunity for civil society and the private sector to ensure rapid response when grant implementation problems are identified 130. The Global Fund acknowledges that independent non-government organizations can play a unique and effective watchdog role in monitoring Global Fund activities to ensure appropriate use of funds, appropriate procedures for governance and quality service delivery. However, currently there are not clear, established mechanisms by which civil society can raise concerns or highlight problems regarding grant implementation before they begin to impact grant performance. 131. While channels for raising problems are created and used already by some in civil society, these channels are ad-hoc, informal, and ways to use them are not transparently and clearly communicated.

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132. Existing structures do not adequately address the above concerns. For example, although LFAs are charged with programmatic oversight, in most cases they only have the capacity to fulfill the financial aspects of these responsibilities. 133. Fund Portfolio Managers (FPMs) vary in their ability and/or capacity to respond to challenges identified by civil society and other constituencies related to governance, monitoring and implementation of grants. 134. While the CCM guidelines recommend that CCMs oversee the effective implementation of grants, many CCMs do not currently have the capacity, resources or inclination to fulfill that role. Moreover, the Global Fund has never clearly defined what it means when it says CCMs have oversight responsibilities over grants. 135. The Global Fund is not an implementing entity. However as a large multilateral financing mechanism, it is in the Global Funds interest to develop a robust strategy to increase the impact of grants and to protect donor investments in grants that are at risk of facing bottlenecks. How the measure would work 136. Summary of overall concept: the Global Fund should develop a road map with clear, easy to understand policies and procedures concerning how and to whom concerns and potential problems about country-level Global Fund-related activities can be raised by civil society, the private sector and other stakeholders. 137. Objectives of the measure: i. To improve the responsiveness of the Global Fund and its stakeholders to grant implementation bottlenecks, and thereby increase the impact of Global Fund resources. ii. To leverage civil societys function as independent watchdog. iii. To establish clear chains of command within the Global Fund regarding timely questions about grant implementation problems. iv. To create external and internal clarity about how the Global Fund responds to reports of country-level grant implementation problems without creating a new, parallel mechanism for doing so.

138. Detailed description of the measure: The Global Fund would establish clear policies and procedures regarding how and to whom civil society and other stakeholders should raised concerns about grant implementation, quality of services, and governance. 139. The Global Fund would orient all partners to these new policies, in particular civil society, the private sector and other partners with a local presence. 140. For example, one possible structure for a new policy could be the following: Part 1: When a grant implementation problem arises, civil society would be expected to raise the issue with relevant CCM constituencies to address and resolve the problem at the forum of the CCM. Part 2: If that is unsuccessful or unfeasible, civil society would be expected to raise the issue with their Board members in order to address and resolve the problem. Part 3: If that effort is also unsuccessful or infeasible, stakeholders would be expected to contact a representative within the Global Fund Department of Operations who would take on the task of responding to and addressing these problems. Assumptions 141. Assuring effective program implementation is a major priority for the Global Fund Board, Secretariat, donors and other partners. 142. Civil society can play a unique role in monitoring Global Fund-related activities and that this role is valued by the Global Fund Board, Secretariat, donors and other partners as a way of identifying challenges in effective governance and program implementation. 143. Information can be readily disseminated about how to use this mechanism and that information about how the mechanism is used would be collected, analyzed and reported. 144. Mechanisms such as the Global Fund Early Alert and Response System (EARS), which only flags grant implementation bottlenecks, would complement and not duplicate these new policies and procedures.

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Implications 145. Secretariat staff and/or other stakeholders would take on new tasks and/or shift priorities in order to implement these policies. This may have resource implications. 146. The oversight role of the CCMs would have to be clarified and better communicated by the Global Fund, and likewise the CCM may have to increase expertise and capacity in these areas among its membership. 147. FPMs and other relevant Secretariat employees may have to increase awareness of the need to increase systemic engagement with in-country civil society and private sector organizations.

components. As such, the national government has a powerful voice on the CCM and in country-level Global Fund processes. 150. In these kinds of country environments, civil society and private sector representatives often face difficulties in meaningfully engaging in the CCM and in the oversight of grant implementation. While the CCM requirements provide for the representation of civil society and the private sector and encourage that the chair and vice-chair come from different sectoral blocks (i.e., government and non-government), there is currently no explicit requirement for the involvement of the non-government sectoral block in CCM leadership. How the measure would work

Measure 7: Require that the CCM chair and vice-chair be from different sectoral blocks (i.e., government and nongovernment) [Measure reproduced verbatim from GF/PSC5/05] Opportunity for enabling greater contribution from civil society and the private sector 148. The Framework Document calls for the CCM to be at the highest national level responsible for national multi-partner and multisectoral development planning.2 This high level, together with the fact that CCMs are charged with applying for and overseeing millions of dollars in grant funds, means that CCM leadership positions often carry significant symbolic and political weight at the country level. 149. In most countries, a representative of the national government chairs the CCM: A Secretariat analysis of CCMs that submitted proposals in Round 4 shows that a government representative chaired 96 percent of them and that 75 percent also had a government vice-chair.3 A national government department or agency is also often the PR or is otherwise significantly involved in implementation: In Round 4, CCMs with successful proposals nominated a government PR for 65 percent of proposal

151. Summary of overall concept: The Global Fund would require that, at each election of a CCM chair and vicechair, one be a representative of the national government (or governments, in the case of multi-country, regional proposals) and the other a representative of the local non-government sectoral block.4 152. Objectives of the measure: i. To create opportunities for meaningful, high-level, local, non-governmental participation in country-level leadership and decision-making processes relevant to Global Fund grants. ii. To bring the balance of CCM leadership closer in line with the operating procedures of the Global Fund Board and Committees, which themselves ensure that alternate sectoral blocks hold their leadership positions. Detailed description of the measure: 153. Each CCM would classify its members into two sectoral blocks government and nongovernment for the purposes of electing a chair and vicechair. i. Government: This sectoral block would encompass all national and sub-national government representatives. ii. Non-government: This sectoral block would comprise representatives from domestically-based civil society organizations (including faith-based organizations
 The term non-government sectoral block is henceforth used to refer to the set of all non-governmental constituencies at the country level, namely civil society and private sector organizations. Multilateral and bilateral agencies are specifically excluded from this definition.

 The Framework Document of the Global Fund to Fight AIDS, Tuberculosis and Malaria.  Secretariat Analyses of CCM Composition, Rounds 1-4. http://www. theglobalfund.org/en/about/ structures/ ccm_analysis/#4

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and local offices of international NGOs); organizations of people living with or affected by AIDS, tuberculosis and malaria; and the private sector (including local representatives of multinational companies). iii. Representatives from bilateral donors and multilateral agencies would be excluded from the classification process and from holding either of these leadership positions. 154. Each CCM would conduct the election for CCM chair in accordance with its existing established election procedures (including the frequency of elections and the voting process). The chair could be from either sectoral block. 155. The sectoral block other than that of the elected chair would nominate, through a documented, transparent process, a representative to take on the vicechairmanship, whom the CCM would ratify in accordance with its established procedures. 156. CCMs would have to demonstrate compliance with this requirement to be eligible for Global Fund financing. i. The process described above would become one of the Global Funds CCM requirements (and be added to the existing five requirements). ii. CCMs would have to demonstrate compliance with this requirement to be eligible for funding in a new round and at Phase 2 (as is the case for the existing CCM requirements).5 Assumptions 157. By having two different sectoral blocks represented in CCM leadership, there will be greater opportunities for multisectoral cooperation in key CCM tasks and more balance in decision-making. 158. Ensuring the two different sectoral blocks hold CCM leadership positions would lead to greater accountability and the representation of a broader set of views at the country level. 159. By guaranteeing the non-government sectoral block a CCM leadership position the Global Fund would send a

strong message about the value that it places on multisectoral participation. 160. It is possible to select representatives of both the government and the non-government sectoral blocks who are fully capable of serving in CCM leadership positions. 161. The non-governmental sectoral block can coordinate internally to present a unified front. 162. The proposed measure does not conflict with the core principle of country ownership, as the CCM members are free to select a chair from either sectoral block, and would nominate the vice-chair via a documented, transparent process by country-level stakeholders. 163. Ensuring CCM leadership rests with domestic entities, rather than bilateral or multilateral agencies, encourages country ownership (a point already encouraged in the existing CCM guidelines). Representatives of donors and technical agencies can continue to play an active role as CCM members. Implications 164. Each sectoral block within a CCM will need to develop a documented, transparent process for nominating a vice-chair candidate. 165. The Global Fund will need to develop a process for evaluating CCM compliance with this new requirement, taking into account that the frequency of elections varies by CCM.

Note: Two additional sections of this report, Part 1 and Part 3, are available online at www.icssupport.org and www.icaso.org.

 Global Fund. Revised Guidelines on the Purpose, Structure and Composition of Country Coordinating Mechanisms and Requirements for Grant Eligibility. (May 2005); Global Fund. GF/B9/7: Report of the Governance and Partnership Committee. (November 2004).

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