Global Fundamentals

This edition of The Global Epidemic presents a perspective on the innovative Global Fund to Fight AIDS, Tuberculosis and Malaria by Tim France, PhD. Dr. France is the director and cofounder of Health & Development Networks (HDN), a nonprofit organization based in Dublin, Ireland; Pretoria, South Africa; and Chiang Mai, Thailand. Dr. France has worked throughout the developing world with the World Health Organization's (WHO's) Global Programme on AIDS, the United Nations Joint Programme on HIV/AIDS (UNAIDS), and various nongovernmental organizations (NGOs) in preparing HIV/AIDS-related technical guidelines and policy materials, and in developing information dissemination strategies.

HDN aims to mobilize a more effective response to HIV/AIDS and other health- and development-related issues by improving information, communication, and the quality of debate. Between October and December 2001 HDN worked with the Global Fund to promote and support the participation of civil society in the establishment of the Fund. A report of this project, "NGO/Civil Society Perspectives on the GFATM and BTS Members Survey Results" (February 2002) is available on request by sending email to info@hdnet.org. For more information see the HDN web site at www.hdnet.org.

In April 2001 United Nations (UN) Secretary-General Kofi Annan called for a "war chest against AIDS." Now, one intense year later, the inaugural meeting of the Global Fund to Fight AIDS, Tuberculosis and Malaria ("the Fund") has taken place (in January 2002), the first call for proposals has been released, and the Fund's blueprint for moving dollars to the countries that most need them is being rolled out.

This article describes some of the plans for how the Fund will operate, highlights the implications for nongovernmental organizations (NGOs) and other civil society groups working in these areas, and suggests some of the challenges the Fund will face during the remainder of 2002.

Setting the Stage

The launch of the Fund was initially received with skepticism. Following shortly after the UN General Assembly Special Session on HIV/AIDS (UNGASS) in June 2001, many nongovernmental parties were still reeling from the frustrations of their recent introduction to the bureaucratic world of intergovernmental discussion and negotiation. As a result, initial confidence that the call made by Secretary-General Annan just prior to UNGASS for a new multibillion-dollar fund to stem the tide of the HIV/AIDS epidemic would actually come to fruition was low. As a participant in an email discussion forum (Break-the-Silence at www.hdnet.org) wrote in August 2001, "My feeling at this stage is that the Fund may consume more resources in setting itself up than in really implementing initiatives." Another participant commented, "It is extremely discouraging that the Fund is being created in secret with no pretence whatsoever of the transparency promised earlier in the process. Community activists must make clear that a fund that operates in secret will not be supported." (See the December 2001 HDN project report Email Communications and Networking Support to Civil Society Participation in the UN Special Session on HIV/AIDS.) Much of the early concern was focused on the rate of preparations for the Fund. Following years of discontent about a seeming lack of action, the pace suddenly increased too rapidly to permit adequate consultation.

The reasons for pushing the agenda ahead so quickly-most likely related to Secretary-General Annan's personal attention to the Fund-were described as follows:

• to reduce morbidity and mortality in developing countries
• to mobilize further resources (difficult if current resources are not being disbursed)
• to utilize donor contributions that could be forfeited if they cannot be disbursed in the current fiscal year
• to maintain political momentum for improving health in developing countries
• to deliver as soon as possible on global political commitments for improving health in developing countries.

The second dampening effect on early enthusiasm for the Fund came from the first contributions from donor countries. In particular, the "initial" contribution from the U.S. was $200 million; France and the UK offered a combined $234 million [Ed. note: All monetary figures are in U.S. dollars]. This sent a shock wave through the international health community, which feared that these governments, in their rush to be the first to contribute, had set the bar too low for all other countries.

There also was some initial confusion about the purpose of the Fund -- and little wonder. Just a few days before the UNGASS meeting, the media still were talking about the "AIDS fund." Yet at the World Health Assembly a month before that, WHO Director-General Gro Harlem Bruntland already was talking about the "Global Fund for AIDS and Health" (see Technical Briefing, World Health Organization; WHO/DG/SP: 15 May 2001 at www.who.int). The idea of a global health fund was not a new one, after all, and horse-trading on the scope of the Fund among governments and agencies that already had invested in alternative models was clearly hampering the flow of information.

The expansion of the scope of the Fund also has exacerbated the Fund's biggest, but least discussed, problem: a lack of sufficient resources to have any real, meaningful impact. Secretary-General Annan had called for $7-10 billion to support the Fund's work (or a little over 1% of the world's annual military spending, according to Akukwe and Foote in "HIV/AIDS Global Trust Fund: Need for an Equitable and Efficient Structure," published in the June 2001 issue of Foreign Policy in Focus), and that was when he was envisaging the Fund tackling HIV/AIDS alone. As of early 2002 the Fund had garnered around $2 billion-a figure that would make little more than a dent in the three epidemics it is now intended to halt.

Since the initial flurry of donations to the Fund, and especially in the wake of financial fallout from the terrorist attacks on the U.S. on September 11, 2001, contributions from additional governments, the business sector, and private foundations have been almost nonexistent. Around 90% of the contributions to date already were pledged within a week or so of the UNGASS meeting at which Secretary-General Annan reiterated his appeal.

At this point potential donors appear to be waiting in the wings to witness first-hand the impact the Fund is able to make with the monies it has already. A sentiment of commitment among the G8 governments has been reported, but no action has yet been taken. At first, donors were reluctant to contribute until they saw the plans for the Fund and the decision-making processes put in place. Now, outside the glare of the UNGASS arena and the media spotlight it created, they want to see some results before dipping into their pockets.

Again, a fast pace will be needed to build a perception of efficiency and transparency and a new way of doing business around the Fund. A clear understanding among national governments, NGOs, other civil society organizations (CSOs), and the private sector about how the Fund is intended to operate will be essential for creating that perception, as well as for achieving maximum and rapid benefits at the country level using currently available Fund resources.

How the Fund Operates

"A new way of doing business" means many things in the context of the Fund. The first meeting of the Fund board was held in January 2002 in Geneva, Switzerland. The board's temporary predecessor, the Technical Working Group (TWG), was responsible for preparing various guidance documents in consultation with national governments, NGOs, and other stakeholders. The Fund guidelines produced by the TWG are replete with new ideas and conditions that must be addressed before grants can be released. However, three primary conditions define Fund eligibility:

• Fund proposals should be submitted through a Country Coordination Mechanism (CCM), which should include broad representation from governments, NGOs, civil society groups, multilateral and bilateral agencies, and the private sector.
• The Fund will consider only Coordinated Country Proposals (CCPs) that reflect-among other conditions-genuine, broad participation by and ownership of all interested groups.
• Grantees not producing sufficient positive results and impact shall not receive additional funds.

Through the circumstances created by these conditions, the Fund is intended to promote partnerships among all relevant players within any given country and across all sectors of society, in particular to stimulate productive collaboration between governments and civil society organizations. The CCM preferably will build on existing coordination mechanisms, and hopefully promote new and innovative partnerships where none currently exist. If no appropriate coordinating body exists, a new mechanism will need to be established.

The Fund will consider CCPs on the three diseases or interrelating aspects of them, depending on a given country's realities and readiness. It will work with national AIDS plans, national health strategies, and country elements of the Stop TB and Roll Back Malaria programs, as well as poverty reduction strategies and sector-wide approaches. [Ed. note: In other words, the Fund is intended to work with pre-existing national public health plans and programs, as well as country-level implementations of international initiatives including those mentioned here, which were launched by the World Bank and International Monetary Fund (IMF), the WHO, and the UN.]

Individual organizations such as NGOs and other civil society groups may be eligible to submit proposals directly. However, such proposals must clearly demonstrate why they could not be considered under the CCM process at the country level. Criteria for the submitting NGO include the quality, coverage, and credibility of their services and operations.

Quick-Start Arrangements in the Early Months and Years

Special arrangements have been put in place to ensure that Fund resources can be disbursed quickly to programs that seem good prospects for early success-to "get some money out," as one official working with the Fund has put it (from a transcript of discussions with TWG officials during the NGO Consultation Meeting on the Fund, held in Brussels, Belgium, November 12-13, 2001). With the Fund operational in early 2002, the latest credible deadline for these disbursements to be made will be around the middle of the year or earlier. During the quick-start period, however, both the content of CCPs and the way they are reviewed will be under close scrutiny, sending important signals about how the Fund intends to operate. Fund administrators may have to soften slightly the conditions for proposals in this early stage, yet at the same time they must be cautious not to lower quality standards or undermine the principles so carefully honed to govern access to the Fund in the future.

One option for the quick-start period is for the Fund to support key components of existing country-led plans and programs already operating, as well as scaling up innovative pilot projects that meet the Fund's criteria and that have well-defined funding gaps. According to TWG documents published in December 2001, the Fund board already is considering a variant of this option: "It is recognized that there are a number of countries which are ready to scale up effective interventions to tackle HIV/AIDS, tuberculosis (TB), and/or malaria almost immediately. Factors that indicate readiness include: 1) solid multisectoral partnerships among key government, NGO, bilateral, multilateral, and private sector representatives; 2) strategic and high-quality national policies and plans; and 3) implementation capacity, including microplanning, monitoring and evaluation mechanisms, and staffing and systems to operate and scale up proven district- and community-level interventions."

The Fund also could consider proposals covering only one of the three diseases, creating a "window" that could then be closed in subsequent years. Review delay is one thing that the board can control, and in any scenario the review process, from the closing date for submission of proposals to the country notification of the review outcome, is intended to be completed within six to eight weeks.

Other Fund Structures

Partnership Forum

The Partnership Forum is an informal platform for open and transparent discussion among all stakeholders to express their views on fund policies and strategies. Open meetings will take place every two years, or perhaps more frequently in the early years. The forum will:

• review progress based on reports from the board and provide advice to the board and the chair on general directions for the Fund
• provide an important and visible platform for debate, advocacy, continued fundraising, and inclusion of new partners
• mobilize and sustain high-level coordination, political commitment, and momentum to achieve the Fund's objectives
• provide a communication channel for those stakeholders that are not formally represented elsewhere in the governance structure.

While on the one hand participation in the forum is intended to be open to a wide range of stakeholders that actively support the Fund's objectives, currently available documents add some confusion by stating that "the board will establish criteria for participation and rules of procedure [in the forum]."

Technical Review Panel

The Technical Review Panel (TRP) is an independent, impartial team of experts appointed to guarantee the integrity and consistency of the proposal review process. The TRP will make recommendations to the board regarding approval or rejection of proposals that come from countries. What the TRP recommends shall, therefore, carry a great deal of weight.

The review process is facilitated by the Fund secretariat, which will receive proposals and ensure that all the required information is included, then forward them to the TRP, possibly with some pre-vetting by appropriate technical experts.

Secretariat

The secretariat is responsible for day-to-day management of the Fund. It is comprised of a team of 12-15 professionals with associated support staff. The secretariat offices are based in Geneva, and its functions are to:

• oversee the CCP receipt and review process
• commission the TRP and ensure the independence of the review process
• coordinate processes and proposals to recommend TRP and other advisory group candidates to the board
• coordinate the preparation of issues papers and operational strategies for the Fund for board meetings, and commission and supervise contracted work
• coordinate with relevant agencies
• communicate the board's decisions to stakeholders
• oversee the monitoring and evaluation process
• support the board in advocacy and fundraising
• organize and prepare for meetings of the Partnership Forum.

NGO/Civil Society Recommendations for the Fund

During pre-Fund consultations in late 2001, NGOs and CSOs from around the world made a set of recommendations about the Fund. (See Key Recommendations from the NGO Consultation Meeting, November 2001, to the TWG. These comments also were compiled with reference to NGO inputs previously shared through the Break-the-Silence email discussion forum and its 3,000 members; see Global Fund at www.globalfundatm.org or www.hdnet.org for further details.) These recommendations mostly sought to ensure the direct participation and eligibility of NGOs and CSOs in the operations of the Fund. Some of these suggestions already have been wholly or partially addressed by Fund decisions to date, and others must be underlined as essential for revisitation and elaboration by the Fund board:

• NGO/CSO participation must be ensured in Fund decision-making and activities at all levels.
• The CCM must bring together all key stakeholders, including NGOs, civil society groups, and representatives of people living with and affected by the three diseases covered by the Fund.
• The CCM should build on existing structures. However, it must be recognized that currently these are rarely truly participatory, and action must be taken to ensure that all stakeholders can participate effectively.
• In addition to the CCP option, the Fund must provide a contingency for national NGOs and CSOs to access the Fund directly.

Immediate Challenges for the Fund in 2002

Demonstrate Transparency

Clearly one of the greatest tests of the Fund is, and will continue to be, the level of transparency it is able to generate around its work, and the Fund has set itself high standards in this area. According to TWG documents from December 2001, "A new way of doing business is needed so that the entire process is transparent and demonstrates an ideal partnership. Funded proposals should be made widely available to ensure this transparency and to provide models for future proposals." Elsewhere, the documents also state that "all fiduciary arrangements, including audits, should be fully transparent to stakeholders and others interested in the activities of the Fund." In addition, "An independent, impartial annual assessment of progress at the country level will be done. To maintain neutrality, the review should not be conducted by the implementing partner, i.e., if a government is implementing a program, an NGO might conduct the review and if an NGO is implementing a program, a government agency might conduct the review."

In order to ensure maximum transparency, all Fund proposals, interim and final reports (as well as other supporting/review documentation), and working documents of the board, secretariat, and Partnership Forum should be available publicly and for comment in a timely manner. Submitted comments should be made available to the TRP within the established proposal review time frame.

All recruitment and deployment of secretariat staff, TRP members, and national monitoring panels should be carried out in an open way. Clear strategies also should be developed for managing-i.e., rather than preventing-the inevitable conflicts of interest that will arise during the handling, review, and evaluation of proposals and programs by individuals and/or institutions that potentially stand to benefit from the Fund's resource allocation decisions.

HIV/AIDS, TB, and Malaria: an Easy Synergy?

The greatest rationale for responding to three diseases collectively may be that doing so suits agendas created by donors who want to see fewer resources spent for greater impact. Viewed in terms of epidemiology, treatment, or prevention for the three conditions, some commonalities exist but so do many differences. Existing programs and other country-based mechanisms do not, and have not until now, lent themselves easily to working on all three as a package.

In what seems at first to be a counterintuitive motivation, driven largely by priorities of international organizations and the governments of richer nations, it may be that the previous arbitrary separation of programs to address the different diseases is also driving thinking in the direction of combined initiatives. During one of the preparatory meetings, a UN official working closely with the Fund explained: "We are talking about HIV/AIDS, TB, and malaria. There are a lot of health system issues that provide great opportunities for synergies between the responses-and we should try to maximize those as much as possible.... Currently you tend to get very vertical programs. Roll Back Malaria sets up its own programs, vehicles, or whatever. Stop TB does the same, and HIV/AIDS again does the same. You get a lot of duplication in management, in operations, in committees. Can we use the Fund to leverage, over time, a coming together of all these responses and the policy issues that deal with them?" (From the transcript of discussions with TWG officials during the November 2001 NGO Consultation Meeting on the Fund.)

Combining such a programmatic focus with the language of "measurable high-impact interventions" and the pressure to generate results quickly means, however, that the Fund may well fall into the "quick-fix trap." This will happen if programs continue to focus exclusively on technological quick-fixes that are high-impact and cost-effective in the short term-for example, through provision of preventive or treatment technologies like condoms or curative drugs.

Unless a balanced approach is found between treatment, care, and enhancing community capacities to respond to these conditions, the biomedical model will continue to prevail in the medium term. This, despite the constant and deafening advocacy insisting that these diseases are not merely health issues, but rather are driven by poverty, deep-rooted developmental constraints, and enduring societal constructs about sex, health, and death.

The obvious challenge and risk for the Fund is that a focus on quick results, essentially to generate more donor confidence, will do nothing to enable long-term development responses or the capacity of communities to respond to these diseases themselves. The absence of long-term, self-reliant development as an outcome might, ironically, undermine donor satisfaction with the Fund's performance.

Fostering Genuine Partnerships in the CCM Process

The most important factor in determining the perception and ultimate fate of the Fund is the extent to which it can encourage genuine multipartner coalitions at the country level. The initial intention is to work through existing mechanisms that already bring together government, academia, NGOs, CSOs, the private sector, health worker associations, and international partners in the CCP formulation. The paradox is, of course, that if this type of mechanism were already in place and working, there would be no need for the Fund at all.

In many countries, the relationship between government departments and NGOs is far from equal, with NGOs often regarded as subcontractors at best. But perhaps more challenging will be opening government/NGO collaboration beyond established relationships with organizations favored by governments for reasons of mutual benefit and credibility or a track record of acquiescence. As expressed in a posting to the Break-the-Silence email discussion forum, "Most national health programmes pay lip service to NGOs willing to collaborate, and NGOs are treated as stepchildren with less than 1% of funds being allotted to them. It appears that the Fund will also follow the same practice and allocate most funds to CCMs that continue to pander, while credible NGOs languish for want of resources."

This phenomenon is not only about escaping from existing government/NGO cronyism: it also highlights the lack of capacity and experience on the part of most NGOs in working with government and other potential partners, as well as in preparation of meaningful national-level proposals. A means must be established through which resources can be invested in developing such capacity at the country level, and the Fund itself should support such programs among important NGO groups. As stated in another posting to the Break-the-Silence forum, "If [the] Global Fund committee is truly interested in receiving well-prepared and well-coordinated applications with equal partnership among government, private, and NGO sectors, they should invest in assisting NGO/private sectors to coordinate their efforts with the government sector."

The realities and constraints this process will face in many countries must not be underestimated, and the barriers to NGOs and governments working together, for example, must not be overlooked. Rather, constraints and barriers must be broken down in a practical and proactive way.

Developing Appropriate Indicators of Progress

"Results-based funding" by the Fund means there must be an explicit, agreed-upon way to monitor and evaluate progress. The first challenge will be whether the Fund can separate out the impact of the programs and activities it directly supports. But measuring national progress overall is no less challenging. The Fund will have to develop or adopt a set of internationally recognized core indicators for baseline and progress measures. This will have to take place in an open and consensual way, so that there can be no dispute in the future conduct of the Fund about what constitutes "progress" and what does not. A working group has been established by the Fund board for this purpose, but its discussions and work to date have not been made public.

"For purposes of the payment of tranches, the Fund need not attempt to distinguish results due to the Fund's financial support from results due to the other donor support. Rather the country could be rewarded by the Fund for its overall success in using the resources available to it, from whatever source they may be." (From TWG documents published in December 2001.)

Preserving Donor Coordination at the Country Level

The Fund has been described as a source of new donor funding, and a repeatedly asserted precondition for the Fund's existence is that it will not divert existing bilateral assistance from current programs. At the country level, however, the Fund is targeting "key components of existing country-led plans, already operating programs, as well as the scaling-up of innovative pilot projects," particularly during the quick-start phase. This raises a critical question: to what extent are such existing plans already funded through direct bilateral or cooperative funding schemes?

Enormous efforts during the past five to ten years among donors to coordinate their support at the country level-to avoid overlap between funded programs and resulting duplicate funding, for example-might now be confused by the entry of a new, significant source of funding.

Consider the first round of funding proposals submitted to the Fund as an example. Governments were given a little over five weeks between the initial call for proposals and the submission deadline. They were expected in that time to develop proposals among multiple stakeholders according to a complex set of guidelines and principles. Yet the most that any government could possibly do in such a short period of time would be to repackage an existing action plan or proposal, many of which are already partly or fully supported by donors. Doing so potentially creates precisely the type of duplication, overlap, and inefficiencies that donors have been striving in recent years to reduce.

Initial disbursements from the Fund will have to strike a balance between the quick-start imperatives for the Fund itself and the need to preserve coordination at the national level, i.e., among the very same donors the Fund is trying to court internationally. Otherwise donors' embassies in developing countries will be sending unwelcome messages about the Fund's initial performance back to their national governments.