France announced that it will contribute approximately $467 million a year to the Global Fund for the period 2014–2016. This is about the same amount as France pledged for 2011–2013.

The Global Fund has established a Grant Management Assurance Framework, also referred to as the “risk framework,” that sets out the Global Fund’s risk management approach. The Framework is described in a report prepared by Chief Risk Officer Cees Klumper. This article summarises the Fund’s general approach to managing risk.

The Global Fund’s Grant Management Assurance Framework outlines specific measures to combat fraud. This article provides a summary of these measures.

A new report from Open Society Foundations says that local civil society participated extensively in the development of concept notes in Myanmar and Zimbabwe.

Civil society played a prominent role in the development of the concept note in El Salvador. The country was one of the first applicants under the new funding model to be awarded funding.

This article provides a summary of the outcomes of a meeting of the NGO and Communities delegations on the Global Fund Board to discuss recent developments in the implementation of the new funding model. At the meeting, staff from the Secretariat acknowledged that the allocation model needs to be better explained.

The Global Fund says that all countries not participating in the transition phase should be preparing now to submit a funding request in early 2014.

Following online and regional consultations, the Eurasian Harm Reduction Network has submitted a draft project concept to the Global Fund for review by the Secretariat and the Technical Review Panel. The next step for the HIV and harm reduction initiative will be the submission of the concept note itself.

The Ethiopian government looks set to achieve universal antiretroviral coverage, a goal it committed itself to in 2006. The country has boosted the provision of antiretrovirals and has strengthened its health systems by building health centres and mobilising health workers and volunteers. The country has been singled out by the Global Fund for these achievements. However, Ethiopia still faces a number of challenges.

A new guide from the International Council of AIDS Service Organizations describes how civil society can participate in applications under the new funding model.

France has announced that it will contribute € 1.08 billion ($1.4 billion) to the Global Fund for the Fourth Replenishment period (2014–2016). That works out to about $467 million a year. This approximately the same as the amount France pledged for the Third Replenishment (2011–2013).

There had been fears that France would lower its contribution. However, in recent months, France tried to dispel these fears (see GFO article).

France is the largest European contributor to the Global Fund. Globally, France is second only to the US, which pledged about $4.0 billion for the Third Replenishment.

“Despite having to make difficult budgetary adjustments in many areas, France has made the right choice in maintaining its strong commitment to this critical fight,” said Mireille Guigaz, Vice-Chair of the Global Fund Board and France’s former Ambassador for the fight against HIV/AIDS and communicable diseases.

Global Fund Executive Director Mark Dybul said President François Hollande was showing strong leadership in reaffirming France’s financial backing for the Global Fund. “France has for years tirelessly defended the Global Fund’s founding values, which emphasize the key role played by communities affected by the diseases, by civil society and by recipient governments.”

It is expected that up to 5% of France’s pledge will be earmarked for capacity-building activities in Francophone countries aimed at improving the effectiveness and health impact of Global Fund grants. France started this practice in 2011.

Some of the information for this article is from a Global Fund news release.

In the last two years, the Global Fund has implemented a comprehensive set of measures to better manage risk, particularly the risk of fraud and misappropriation of grant funds. The Fund has established a Grant Management Assurance Framework (also referred to as the “risk framework”) that sets out the Global Fund’s general approach to managing risk. The Framework allows the Fund to identify, document, assess and act on all risks that could affect the success of a grant.

The Framework is explained in a report prepared by Chief Risk Officer Cees Klumper, recently posted on the Global Fund’s website. The Framework describes the Global Fund’s general approach to risk management and specific measures to combat fraud. In the next article in this newsletter, GFO describes specific measures to combat fraud.

Main elements

The Grant Management Assurance Framework covers four main elements:

• assessment of proposed implementers’ capacity;
• use of the Qualitative Risk Assessment, Action Planning and Tracking Tool (QUART);
• risk analysis of implementation arrangements; and
• greater flexibility to manage risk.

Each element is described below.

Assessment of proposed implementers’ capacity. For each new grant, before it is approved, an assessment is done of the proposed implementers’ capacity to implement the grant. This applies to all principal recipients (PRs), large sub-recipients (SRs) and other actors, such as public or private entities involved in health product procurement and storage. For this exercise, the Global Fund uses a set of minimum standards developed several months ago (see GFO article). For PRs, the assessment measures their capacity to manage their operations and oversee SRs from both a programmatic and a financial perspective. Any weaknesses in capacity that are identified are usually addressed before the grant is signed. Where this is not possible, action is taken to mitigate the risk – for example, by outsourcing procurement to another entity.

QUART. For what the Global Fund Secretariat considers “important” grants: As each grant is being implemented, the Secretariat uses a tool called “QUART” (Qualitative Risk Assessment, Action Planning and Tracking Tool) to routinely review 19 risk areas (see table). Two of the risk areas directly cover fraud and misuse – “Fraud, Corruption, or Theft of Global Fund Funds” and “Theft or Diversion of Non-financial Assets.” Assessments of some of the other risk areas – such as inadequate governance and oversight, and treatment disruptions – may also signal a possible risk of misuse of grant funds. When using QUART, grant managers are required to assess the factors that contribute to each risk and to evaluate their likelihood and severity.

“Important” grants include all grants from high-impact countries that had a certain minimum length of time remaining. They also include other grants that have a certain minimum length of time remaining and that are above a certain value. 

Table: List of 19 operational risks in the Global Fund’s risk framework

Note: This table is reproduced from the Global Fund’s report on risk management.

Risk analysis of implementation arrangements. Building on the implementers’ capacity assessments (described above), once implementation of a grant starts, the performance of the “main” implementers – i.e. implementers that collectively account for a sizeable portion of the portfolio –  is reviewed in areas where risks were identified during the assessments. The success of any special measures put into place to mitigate risks (such as outsourcing) is also reviewed. Where required, additional mitigating measures are taken.

Greater flexibility to manage risk. The Global Fund has adopted a system which allows it to allocate more resources to grants that pose the greatest risks. The new system replaces the one-size-fits-all approach to managing grants that was previously in place.

Who manages the risks?

The Grant Management Assurance Framework also indicates where risk is managed in the Global Fund. Within the Secretariat, there are three levels of quality assurance. First, the line managers of each country team review and sign off on the documented risk assessment and mitigation action plans that emerged from the review of risk areas using the QUART tool (described above).

Second, risk management experts from the Risk Department, which include former investigators from the Office of the Inspector General, local fund agents, grant managers and auditors, perform in-depth quality assurance assessments of the reviews that were done using the QUART tool. The assessments also provide an opportunity to train country team members on the application of sound risk management practices.

Thirdly, the risk assessments and mitigation action plans are reviewed by a senior level Operational Risk Committee (ORC), co-chaired by the Head of Grant Management and the Chief Risk Officer. The ORC reviews and approves the risk assessments and action plans for individual grants.

The measures described above are complemented by (a) visits to countries by grant managers; (b) the implementers’ own internal control mechanisms; (c) the actions of the implementers’ external auditors; and (d) the actions of the local fund agents. Finally, in-country partners, such as bi-lateral and multi-lateral donors and technical partners, feed into the risk management system.

In this article, we describe specific measures to reduce the risk of fraud. These measures are explained in a report prepared by Chief Risk Officer Cees Klumper, recently posted on the Global Fund’s website.

The specific measures include the following:

• use of local fund agents (LFAs);
• new financial tools;
• revised terms and conditions;
• fraud-related findings from audits and investigations by the Office of the Inspector General (OIG); and
• special measures for high-risk grants.

Each of these measures is summarised below.

Use of LFAs. In 2011, the Global Fund instructed its LFAs to routinely undertake certain activities designed to detect fraud and other misuse of grant funds among principal recipients (PRs) and sub-recipients (SRs). These activities included (a) reviewing high-risk cost categories such as training activities, expenditures related to vehicles, and salaries; (b) performing targeted forensic audits; and (c) undertaking checks on vendors involved in high-risk procurements.

In addition, LFAs are increasingly being asked to conduct spot-check verifications to check for signs of fraud. The verifications are tailored to the specific risks of each grant. They involve reviewing procurement bids, invoices, and training and meeting attendance forms. More and more, the verifications are being conducted among implementers below the PR level.

New financial tools. The Secretariat has implemented a new and improved financial planning tool for managing grants. The tool will allow for the tracking of grant expenditures. It will enable the Global Fund to see what the major categories of expenditure are at the level of the overall grant portfolio. The tool will also provide information on what unspent grant funds will be used for in future.

This tool – when combined with (a) assessments of controls in place to prevent and detect inappropriate use of funds; and (b) the new risk framework – will enable Secretariat staff to identify activities that may involve inappropriate expenditures (while the activities are in the early stages of being implemented).

In addition, a treasury function has been established (for the first time at the Fund). Staff in this unit are currently designing systems and tools that will result in better management of cash flows to grant recipients. One of the tools will be an automated mechanism of releasing cash to recipients in a “more staggered” manner than is the practice today. In this instance, “more staggered” means more frequent disbursements, but in smaller amounts that are more in line with the need for funds.

Collectively, the new financial tools described above will enable the Global Fund to increase the level of security and thereby minimise the financial exposure associated with misuse of funds and fraudulent activities.

Revised terms and conditions. The Secretariat has implemented revised standard terms and conditions (STCs) for grant agreements. The revised STCs incorporate multiple codes of conduct which explicitly forbid fraud and abuse of Global Fund money. This means that PRs contracting directly with the Global Fund have a legally binding commitment to ethical behaviour. The STCs incorporate a new Code of Conduct for Suppliers that establishes the principles and standards of conduct required of all recipients of Global Fund grant funds. The grant agreements with PRs require that the PRs incorporate the relevant provisions of the STCs into contracts that they sign with sub-recipients, suppliers and other agents.

Fraud-related findings from OIG audits and investigations. Through its audits and investigations, the OIG has been able to deconstruct some pretty elaborate fraud schemes. The Global Fund Secretariat uses this information to improve the Fund’s financial and management controls.

For instance, much of the procurement-related fraud identified by the OIG concerns small procurements done in remote areas – e.g. for purchasing food and supplies for trainings. Evidence of procurements for such goods is often forged. So, the Secretariat has launched a pilot project. Under this project, the requirement to provide evidence of procurements for these goods is removed, and is replaced with a system where LFAs make random, unannounced visits to the activity sites.

OIG reports have highlighted the risk of drug theft and counterfeiting. In response, the Global Fund has undertaken multiple assessments to gauge the severity and likelihood of this risk. In 2011, working with partners, the Secretariat piloted action plans in 20 countries to better mitigate this risk. In addition, an internal working group is currently meeting with supply chain experts in the private sector to explore the possible use of harmonised measures and technology to improve tracking and anti-counterfeiting throughout the supply chain.

In 2011, to combat money laundering, the Global Fund added provisions to the grant agreement STCs regarding wire transfers and related financial transactions. The STCs require that all transfers of grant funds be carried out only through the PR’s beneficiary bank; and that PRs properly record all wire transfers and currency exchanges involving grant funds. The STCs prohibit all transfers of grant funds for non-programmatic purposes. Finally, the STCs require PRs to include equivalent requirements in all agreements with SRs.

Special measures for high-risk grants. The Global Fund is making increasing use of several risk mitigation measures for grants that have been identified as having a high risk of fraud and misuse of grant funds. These measures include the following:

• reducing investments in high-risk activities;
• restructuring portfolios to make them less complex;
• use of fiscal agents;
• direct contracting with external auditors;
• paying vendors directly (“zero-cash policy”);
• donor mapping; and
• engaging with countries’ supreme audit institutions and with international accountancy organisations.

Each of these measures is further described below.

Reducing investments in high-risk activities. Certain activities – such as training, communication campaigns and remunerating staff have been found to be particularly vulnerable to fraud risks. Where such risks are deemed to be particularly high, the Global Fund has worked with recipients to re-design the programme scope to reduce or completely halt investment in such activities. Where higher-risk investments are still required from a public health perspective, the Global Fund helps to identify alternative sources of funding, thereby shifting the risk to other institutions that are better-placed – e.g. by having a stronger in-country presence – to oversee such investments.

Fiscal agents. Where a PR’s financial management and internal controls are particularly weak, the Global Fund has contracted with fiscal agents to work with the PRs. Fiscal agents provide assurance that requests for funds and payments are economically justified, are adequately documented, and are based on the approved budgets and work plans. The Global Fund now has arrangements in place with six international fiscal agents.

Direct contracting with external auditors. In countries where external audits have been of poor quality, the Global Fund is directly contracting independent external audit firms.

Zero-cash policy. For some high-risk grants, the Global Fund has instituted a policy whereby the PR (or the fiscal agent) makes direct payments to vendors of goods and services, rather than transferring funds to SRs for this purpose.

Donor mapping. To guard against “double dipping” – charging multiple donors for the same expenditure – the Global Fund is conducting a detailed mapping of funding provided in countries to identify possible overlaps. This is being done in conjunction with other donors.

Engaging with countries’ supreme audit institutions and with international accountancy organisations. The Global Fund is working with the supreme audit institutions in many countries to strengthen their capacity. In February 2013, the Global Fund signed memoranda of understanding (MOUs) with the International Organization of Supreme Audit Institutions and several professional accountancy organisations. The MOUs describe the Global Fund’s intent to strengthen audit and accountancy capacity in developing countries so that there is sustained improvement in standards of audits, accountancy, financial management and reporting in the public sector.

Office of the Inspector General

The OIG is an independent and comprehensive additional “line of defence” and layer of assurance in the prevention and detection of misuse of funds. It carries out in-country audits and investigations and operates a 24/7 multi-language whistle-blower hotline through which any individual can report suspicions of misuse. The OIG’s charter contains explicit counter-fraud provisions, and a significant portion of the office’s annual budget is dedicated to counter-fraud activities and investigations.

The initial draft of the concept note that Zimbabwe was planning to submit to the Global Fund included funding for studies on the population sizes of sex workers and men who have sex with men (MSM), but did not include specific interventions that could address the needs of these groups while the data were being collected. However, feedback on the initial draft from the Global Fund Secretariat’s country team for Zimbabwe and from the Grant Approvals Committee led to the inclusion of specific interventions in the final concept note. This is an example of the Global Fund’s new iterative approach at work.

This was one of the findings of a preliminary report from the Open Society Foundations (OSF) on local civil society participation in the new funding model (NFM). The OSF conducted 24 interviews with persons involved in the development of the concept notes in Zimbabwe and Myanmar, and an additional two interviews with civil society representatives who were not directly involved. OSF was not able to include data from El Salvador, the third early applicant country, because government and Global Fund officials requested that surveys in that country be postponed until after the concept note was submitted and the grant making was complete. (Editor’s Note: See next article in this issue.)

Two-thirds of the interviews were conducted with civil society representatives. Others who were interviewed included representatives of country coordinating mechanisms, UNAIDS staff and fund portfolio managers. Of the 26 interviews, 18 were with people from Zimbabwe, and eight were with people from Myanmar.

The OSF study looked at both the process of developing the concept notes and at the content of the notes. This article provides a summary of the findings in each area.

Process of developing the concept notes

A major finding of the study was that the country dialogue process involved a wide range of civil society stakeholders, including most-at-risk populations (MARPs) such as sex workers, MSM and people who inject drugs. At the same time, survey respondents pointed out that people living with disabilities, migrants, internally displaced people and youth could have been better represented. In addition, OSF said that participation in the country dialogues was mainly confined to people living in the main cities (Harare and Yangon), at the expense of people from rural areas.

Survey respondents told OSF that the Global Fund Secretariat played a positive role in encouraging the involvement of civil society, including MARPs. For some respondents, this was the first time they were able to input into, or see, Global Fund grant proposals prior to grants being awarded.

Another important finding from the study was that that there were several civil society representatives on the proposal writing teams in both countries. In Zimbabwe, respondents said that the four civil society representatives on the proposal writing team kept in close contact with other civil society stakeholders during the writing process. However, some respondents said it was unrealistic and unfair for a limited number of civil society representatives on drafting teams to shoulder the burden of ensuring this kind of engagement.

The Myanmar CCM had started working on its concept notes in October 2012, prior to the launch of the NFM. This is because the Global Fund had invited Myanmar to apply for some “extra” money it had on hand at the time. When Myanmar was formally invited to participate in the NFM transition phase, the concept notes were redrafted. (Myanmar submitted three concept notes, one for each disease.) Some respondents said that the use of the 2012 concept notes as the basis for the country’s final submissions detracted from the spirit of country dialogue because much of the drafting had already been done.

Respondents from Myanmar also said that language barriers posed a challenge to the broad inclusion of civil society. While interpreters were present at some country dialogue meetings, none of the related documents were translated from English into Burmese.

Respondents from both countries noted that several aspects of the new funding model were confusing, including (a) the way in which the indicative and incentive funding streams worked; and (b) the use of a modular, web-based system for preparing the concept note. One person said that the use of the web-based system was not conducive to sharing drafts among the members of the writing teams because the system could not produce drafts in Word.

Content of the concept notes

OSF said that its findings concerning the content of the concept notes should be interpreted with caution because most of the people it interviewed had not seen the final version of the notes.

OSF said that the draft concept notes in both Zimbabwe and Myanmar included aspects of community mobilisation, community-based programming and community systems strengthening (CSS). In Myanmar, the Global Fund Secretariat specifically asked the country to include a human rights and CSS component, a request that was supported by UNAIDS.

According to one country-level Global Fund official, OSF said, the Fund’s Senior Human Rights Specialist also travelled to Myanmar in March to hold a workshop with civil society that included all nine national networks, as well as representatives of sex workers, persons living with the disease, MSM and transgendered persons.

OSF said that the Myanmar draft concept note contained the following CSS- and human rights–related activities:

• strengthening the support for antiretroviral (ARV) treatment adherence provided by peer counsellors;
• the creation of a community feedback mechanism to allow civil society to monitor the scale-up of, and access to, HIV and TB treatment; and
• policy and law reform to protect the rights of persons living with HIV.

The draft concept notes from Myanmar also included harm reduction activities targeting people who inject drugs, OSF said.

Respondents reported that the Zimbabwe concept note included community-based adherence support for patients on ARVs, as well as funding for community health workers and treatment buddies. It also included support for civil society monitoring of access to treatment.

One of the civil society representatives on Zimbabwe’s drafting team said that it was difficult to argue for the inclusion of CSS-related activities because other proposed activities were easier to cost and monitor. For this reason, this person said, if something had to be cut from the budget, the CCS activities were vulnerable.

Civil society respondents in both countries said that the PRs appeared to be negotiating directly with the Global Fund concerning the final draft of the concept note.

Respondents in both countries noted that data on MARPs is scarce. Respondents from Myanmar said that data on MARPS was included in the draft concept note in order to justify the proposed interventions, but that this data was outdated.

Recommendations

In its report, OSF recommended that the Global Fund develop clear guidance on the steps involved in country dialogue. It also recommended that technical partners produce a costed package of minimum services for CSS interventions and programmes aimed at MARPs.

Next steps

OSF told GFO that it is continuing to interview participants from Myanmar and El Salvador, and that it hopes to release a final report by the end of July. Persons who were involved in the country dialogues in these two countries, and who would like to participate in the survey, can contact Krista Lauer at OSF.

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Editor’s Note: The report of the Grant Approvals Committee on the concept notes approved for early applicants confirms that many of the elements described above were included in the final drafts of the notes. The concept notes from Myanmar included an expansion of harm reduction activities; and interventions targeting sex workers, MSM and people living with the diseases. The concept note from Zimbabwe included activities related to human rights, policy reform and CSS; and interventions targeting MARPs. (See GFO articles here and here.) However, it should be noted that final versions of the concept notes have not yet been made public, so we don’t yet have many details on the contents of the notes.

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The OSF report – entitled “Rapid Assessment of Local Civil Society Participation in the Global Fund to Fight AIDS, TB and Malaria’s New Funding Model: Preliminary Results, June 2013” – will not be posted. However, the final report will be posted on the OSF website once it is published.

Civil society was involved extensively in the development of the concept note that El Salvador submitted to the Global Fund. This is one of the findings from interviews that GFO conducted with five people involved in the process, and from a review of related documents.

El Salvador was one of three countries that have been awarded funding in the transition phase of the new funding model (NFM). El Salvador was awarded $23.1 million for its HIV programmes (see GFO article). The country dialogue and concept note development process in El Salvador was described briefly in a GFO article here. This article provides more details.

El Salvador currently has two single-stream-of-funding (SSF) HIV grants. When Round 11 was launched, the El Salvador CCM began preparing a proposal. At that point, El Salvador had already updated its National AIDS Plan. The CCM undertook a small process of consultation that was abruptly interrupted by the cancellation of the round.

Then, in or around September 2012, the CCM began preparing a request for continued funding for the next implementation period of the SSF grants. The CCM initiated a process of consultation with affected populations – specifically, people living with HIV and men who have sex with men (MSM), both of whom were already represented on the CCM.

These consultations were already underway when the CCM received the invitation to participate in the transition phase of the NFM. According to some of the people interviewed for this article, the invitation was accompanied by a strong message from the Global Fund: A significant part of the project (i.e. at least 50% of the funding) had to go to activities that benefit three key affected populations – transgendered persons, MSM and sex workers.

After receiving this message, the CCM added representatives of these key populations to its Proposal Committee (which had been established to work on the requests for continued funding.)

The concept note development process consisted of three stages: (1) the country dialogue; (2) the work of the Proposal Committee; and (3) the work of the Editorial Committee.

Country dialogue

With the support of its technical partners, the CCM hosted two very large meetings with different stakeholders. Called, “inter-sectoral meetings,” each one brought together more than 120 people, about 80% of whom were from civil society. The purpose of the meetings was to obtain the input of different populations and sectors regarding (a) their needs; and (b) the objectives and activities they thought should be included in the proposal. These were brainstorming sessions; no attempt was made to filter out suggestions which may not have been feasible or which may not have been pertinent to the nature of the epidemic in El Salvador.

“The result of the inter-sectoral meetings was a wish list,” commented Guadalupe de Castaneda, a member of the International Community of Women (ICW) in El Salvador, and a participant in the dialogue. “People could say whatever they thought.”

Most at-risk populations were included in the country dialogue. This was a very new experience for transgendered persons and sex workers, who hadn’t participated actively in the development of previous proposals.

Each population group was able to select the people that attended the country dialogue meetings. In the case of sex workers, since they had no national network, all four of the country’s sex worker organisations were invited. Since El Salvador is a very small country, it was not necessary to pay for hotel accommodation because people could come from their cities and return the same day after the meeting finished. Cost of transportation and food was covered by the organisers.

The committees

The information collected was discussed at the second stage of the process, by the Proposal Committee. This was where the proposal was shaped. The Proposal Committee discussed the feasibility and pertinence of the activities that emerged from the country dialogue, along with evidence that supported each proposed activity. This process involved constant negotiations. Participation in the Proposal Committee afforded the representatives of key populations an opportunity to participate in programme and budgeting discussions. A financial expert was on hand to help with the budget part.

The Editorial Committee was in charge of the actual writing of the proposal. It had regular communications with the Proposal Committee in order to request further information about a suggested activity, evidence to support it, or bibliographic references. No representatives of key populations participated directly on the Editorial Committee.

Content of the concept note

According to the people we interviewed, the participation of key populations led to the inclusion in the draft concept note of some activities that otherwise might have been neglected. One example of this was the decision to include promotion of an identity gender law. This is very important for the transgender population because, currently, they cannot obtain an identity document that says that they are transgender (or even where the photo suggests that they are transgender). Other examples are: (a) strengthening of health facilities (through training and infrastructure improvements) to treat transgendered population and sex workers; new infrastructure for community centres serving mainly MSM; strengthening of national groups of key populations; and food and nutrition support for persons living in HIV who could not afford these items.

“The inclusion of these activities, and others, were the result of long negotiations,” said a representative of the CCM secretariat. “We had to discuss what was possible to be done and what would help to stop the epidemic,” the representative added.

It should be noted that the people we interviewed had not seen the final proposal. A meeting to “present” the final approved proposal will be held on 25–26 July.

Editor’s note: The final concept note has not yet been posted on the Global Fund website. However, we noted in a recent GFO article: “When it reviewed the concept note, the TRP [Technical Review Panel] asked for several clarifications. When the GAC [Grant Approvals Committee] reviewed the concept note, it recommended that the funding allocation for PMTCT be reviewed and that the government be asked to finance a greater share of this programme; that more of the cost savings from efficiencies be directed towards prevention in key affected populations; that more funding be allocated to improving quality of care for persons living with HIV; and that more be done to improve the quality of epi data.”

Other issues

People involved in the preparation of the concept note told GFO that it was not really any easier than preparing a proposal under the rounds-based system. The template may have been shorter, they said, but the amount of information required was not much different. The word limits on the concept note form meant that the CCM had to include a number of attachments in order to provide all of the information requested.

The people we interviewed said the concept note was prepared completely by Salvadorians, and that this was a matter of some pride. In the past, foreign consultants helped the country to prepare the proposals and little transference of knowledge happened; this time was different and all organisations involved in the country dialogue process have gained experience.

Young people participated in the process – their leaders were involved in the inter-sectoral meetings and some negotiations after that – but they were not able to influence the content of the draft proposal. The main reason is that because the epidemic is concentrated in specific groups, the evidence did not support activities focused on the general population. However, the people interviewed said that they will keep pushing for initiatives to address young people.

Although some human rights–related activities were included in the concept note, some participants were concerned that the Office of the Ombudsman was not involved in the development of the concept note.

Terminology

None of the people we interviewed used the term “country dialogue” and only one used the term “concept note.” Most people just used the term “consultation.” This may indicate that at the country level, there is still not a very good understanding of the NFM process.

Editor’s Note: This is the first GFO article written by Lídice Lopez, our new regional correspondent for Latin America and the Caribbean. Lídice is based in Lima, Peru. Lídice collaborates with the International HIV/AIDS Alliance on its Corresponsales Clave (Key Correspondents) Initiative.

The two NGO delegations and the Communities delegation on the Global Fund Board met in Paris on 19–20 May to review recent developments in the implementation of the new funding model (NFM) and to develop a plan to improve communications and advocacy on this issue. Representatives from early and interim applicant countries were also present.

The Global Fund Secretariat provided an update on the transition phase and on lessons learned from “accelerated” early applicants – i.e. those early applicants that have already submitted concept notes (Myanmar, El Salvador and Zimbabwe).

The Secretariat observed that the final amount for an applicant’s indicative funding is determined by the country teams, which make adjustments to the initial allocation based on qualitative factors such as grant performance, willingness to pay and the rate of new infections. (The initial allocations for early applicants were determined when the NFM was launched in February.) If the final figure is higher than the initial allocation, the proposed allocation is reviewed by the Grant Approvals Committee (GAC). So far, the Secretariat said, this process has resulted some final allocations indeed being higher than the initial allocations. The Secretariat said that this will require downwards adjustments to the funding ceilings provided to other early and interim applicants.

The Secretariat said that the underlying approach of the allocation model needs to be explained better.

The Secretariat said that where epidemiological data is missing or is of poor quality – which is the case for many key populations – this present a significant challenge under the NFM. The three Board delegations echoed this concern. They pointed out that in Zimbabwe, the lack of data on men who have sex with men resulted in this group being left out of the concept note. Given the important role of epidemiological available data on key affected populations in the determination of the allocation of funding, this is considered a huge concern.

The Secretariat said that the greater involvement of the Technical Review Panel (TRP) and country teams in the concept note development process was well received among early applicants.

According to the Secretariat, two aspects of the concept note development process have been challenging: (1) the use of the budgeting and performance tool; and (2) the description of, and the request for, incentive funding.

The Secretariat said that the people involved in the accelerated early applications viewed the engagement with key populations as a critical and rewarding part of the process. However, many of them said that country coordinating mechanisms (CCMs) will require additional support to facilitate this process.

According to the Secretariat, the TRP said that for the three early applicants, the amount of unfunded quality demand was far greater than the amount of resources available.

The Developing Country NGO Delegation said that in an effort to ensure that its constituency has reliable and timely information on the NFM, eight regional focal points are being identified and trained. In addition to supporting regional communication strategies about the new funding model, regional focal points will support documentation of lessons learned.

Meeting participants noted that although the country dialogue presents an important opportunity for greater engagement of communities and civil society, actual engagement is highly dependent on clear and timely communication. One participant noted that in the case of Zimbabwe, participation of the Global Fund Secretariat in the country dialogue greatly facilitated the involvement of key populations because “the government was not given a choice.”

Some of the meeting participants said that when technical partners are relied on to facilitate the country dialogue, as was the case in Myanmar, there is a risk that these partners will involve mainly those groups it is used to working with, such as international NGOs, at the expense of more community-based organisations.

The following concerns were raised by meeting participants:

• Communications on the NFM are still not adequate, particularly in terms of the language of the communications and the forums used.
• Roles and responsibilities of the participants in the country dialogues have not been established.
• There is a lack of clarity and transparency concerning the country dialogue process, including, for example, at which points civil society will be involved, and when concept note narratives and budgets would be shared.
• There needs to be a mechanism in place to address situations where support for the country dialogues or the engagement of key populations is inadequate.
• There is a danger that reliance on national strategies will result in the exclusion of the needs of key populations if those strategies were developed without effective multi-stakeholder involvement.
• There are still many questions about how queued quality demand will be managed.
• Technical partners and country team members often lack knowledge of civil society and community issues.

During the discussion on regional early applicants, some participants stressed the need for dedicated resources for regional proposals and for guidance that is specific to regional proposals.

Meeting participants agreed on the following communications and advocacy objectives:

• to improve the level of knowledge and engagement of communities and civil society players at country level with the NFM through improved communication and information sharing;
• to increase the inclusion of key affected populations in the development of Global Fund proposals and to ensure budgeted interventions to meet their needs;
• to ensure that all technical partners and the Global Fund Secretariat provide accurate, timely, clear information about NFM for civil society and key populations, and that roles and responsibilities are clearly defined among technical assistance providers; and
• to identify capacity gaps so as to be able to cost the capacity building and support needed at country level for civil society, communities and key populations to engage in the iterative country dialogue and concept note development processes.

Participants also developed an action plan to achieve these objectives. The three Board delegations will review the objectives and the action plan in the near future.

Information for this article was taken from a report on the Joint Global Fund Board NGO and Communities Delegations Meeting. The report is expected to be posted on the website of International Civil Society Support.

The Global Fund is advising all countries not participating in the transition to the new funding model (NFM) – referred to as “standard applicants” – to begin preparing now for a funding request in early 2014 (assuming that this timeframe fits their national cycles).

The Secretariat says that countries should be: (a) strengthening their country dialogue, especially with key affected populations; (b) strengthening their national health and disease strategies; (c) identifying programmatic and funding gaps; (d) prioritising needs across diseases; and (e) reviewing eligibility requirements for country coordinating mechanisms to ensure that they comply.

The Secretariat says that if countries work on these areas prior to the full roll-out, the time it takes to develop a concept note will be significantly shortened.

The NFM Transition Manual provides guidance to countries on the steps outlined above. See the section on “standard applicants” in the main text; and Appendices 1 and 3 (in particular).

The Secretariat told GFO that by mid-July, all country teams will have been trained on what they and countries can be doing now to prepare for the full roll-out; and will have received presentations they can use to communicate this guidance to countries.

The Secretariat also said that the Global Fund has been discussing this topic with technical partners, civil society organisations and networks of key affected populations so that they understand how they can help countries prepare for the full roll-out. 

Finally, the Secretariat said that the written guidance available online will be enhanced as the Secretariat incorporates lessons learned from the early applicants.

The Eurasian Harm Reduction Network (EHRN) has submitted a draft project concept to the Global Fund for review by the Secretariat and the Technical Review Panel (TRP) prior to submitting a full concept note. EHRN is the applicant for a regional initiative in Eastern Europe and Central Asia (EECA) on HIV and harm reduction. This is part of the transition phase of the new funding model (NFM).

EHRN provided an update on its project in a report dated 3 July.

EHRN has held several online consultations and also organised a regional meeting on 13–14 June in Vilnius, Lithuania. The consultations helped EHRN establish the project’s goals, objectives and governance structures.

The goal of initiative is “to increase successful advocacy driven by people who use drugs in EECA to expand domestic funding for, and increased quality of, basic harm reduction services in the transition to sustainable national ownership.” The objectives of the initiative are as follows:

1. to increase the level of domestic funding for essential harm reduction services of appropriate quality in countries that are currently transitioning, or have recently transitioned, from international to domestic funding, to ensure sustainability; and
2. to build the capacity of the community of people who use drugs to advocate on issues of access, quality and sustainability of essential harm reduction services.

Through the consultations process, EHRN has agreed that the process for identifying the countries that will participate in the initiative will involve an open call for expressions of interest from civil society and community-based organisations.

The consultations also helped to determine the governance structure for the initiative. Three bodies will share responsibility for concept note development, grant implementation and grant oversight: a Steering Committee, a Regional Oversight Committee and a Regional Technical Advisory Group.

Further information can be obtained from Sergey Votyagov or Ivan Varentsov, the focal points at the EHRN Secretariat for the regional application. 

Ethiopia is often cited by the Global Fund as having done a good job of implementing HIV grants and of strengthening the country’s health systems. When he signed two grant agreements worth $424 million with the Ethiopian government in July 2012, then Global Fund General Manager Gabriel Jaramillo said that the country had made great progress in achieving universal coverage of antiretroviral (ARV) treatment.

“From the day when Ethiopia was the first to set the goal of universal coverage, our partners here have shown tremendous courage and vision. It is phenomenal how much they have achieved, and how much more they are now aiming for,” Mr Jaramillo said.

Simon Bland, then Chair of the Board of the Global Fund, who also attended the grant signing ceremony, said: “We’ve just signed a grant that enables an African country to achieve universal coverage of ARVs. If we had tried that five years ago, we’d have been laughed out of the room. It is astonishing.”

According to a news release from the Global Fund, annual HIV-related deaths dropped from 99,000 in 2005 to 44,000 in 2011. The death rates for children under the age of five fell by half between 2000 and 2011.

There appears to have been three principal reasons for this change: (1) greater availability of ARVs; (2) an improved health system, including at the community level; and (3) strong political commitment.

The Ethiopian government has made the fight against HIV a national priority. HIV is one of the components of the National Plan for Accelerated and Sustained Development to End Poverty. In 2006, Ethiopia signed on to the UN General Assembly’s Political Declaration on HIV/AIDS, which includes a commitment to achieve universal access to HIV prevention, treatment, and care and support services by 2010.

The Global Fund news release quotes Tedros Ghebreyesus, Ethiopia’s Minister of Health and chair of the country coordinating mechanism, as saying that his country’s advances fighting HIV succeeded because outside support was implemented within a broader domestic strategy to improve health care in a sustainable way. That includes the construction of thousands of health centres and the mobilisation of thousands of health workers and volunteers, he said.

“The Ethiopian government has been able to achieve such success in its HIV and malaria programmes largely because of strong leadership and ownership, enhanced community involvement and improved access to services,” Lera Meskele, Deputy Director General of the Federal HIV/AIDS Prevention and Control Office, told GFO.

“Ethiopia has employed three strategies in its fight against HIV/AIDS: strengthening community based health services (such as using a house-to-house service delivery model), expanding service delivery points (using task shifting) and introducing the Millennium AIDS Campaign,” Mr Meskele added.

The Millennium AIDS Campaign was specifically designed to increase HIV testing.

Mr Meskele said that over 38,000 health extension workers have now been deployed to all kebeles (the lowest level administrative units) across Ethiopia. These health workers facilitate community discussions which enable people to discuss and tackle their health challenges.

A key challenge Ethiopia has tried to overcome has been low access to health care services. Thus, as part of health systems strengthening, Mr Meskele explained, primary health care facilities were constructed and equipped with funding from the Global Fund and other sources.

“For every health centre constructed through international support, the local government constructed a matching health centre as an expression of its commitment to achieve universal access,” Mr Meskele said.

(In a recent GFO article, we reported that, historically, access to health services at the district and zonal level in Ethiopia has been a serious problem. In 2005, only 60% of the population lived within 10 kilometres of a clinic or other health service delivery point. However, in recent years, Ethiopia has scaled up health posts, which are staffed by health extension workers, and the larger health centres, such that the ratio of health facilities to population is now 1:5,426, close to the national target of 1:5,000.)

“Through these efforts, the number of sites providing children's home and community treatment services increased from 659 in 2005 to 2,800 in 2011, while the number of ARV sites increased from three in 2005 to 845 in 2011,” Mr Meskele said. “The number of people tested for HIV in a year increased from less than half a million in 2005 to 11.9 million in 2011. The number of people currently receiving ARVs increased from 3,221 in 2005 to 274,000 in 2011.

Another major challenge facing the fight against HIV/AIDS, according to Meskele, is stigma.

“Many communities have adopted bylaws that aimed at reducing stigma and discrimination to people living with HIV and contributed their part to provide care and support to AIDS orphans,” Mr Meskele said. 

Mr Meskele said that Ethiopians have also abandoned cultural practices that promote the spread of HIV. Widow inheritance, he said, has been stopped. A new practice of pre-marital HIV testing has become common among young couples. Community opinion leaders such as politicians, administrators, religious leaders, elders, tribal leaders and health extension workers get tested for HIV as an example to others. 

Despite its achievements, Ethiopia still faces a number of challenges, according to Ethiopia’s Country Progress Report on HIV/AIDS Response, 2012. Use of prevention of mother-to-child transmission (PMTCT) services is very low; only about 24% of pregnant women are actually tested and a much smaller proportion receive ARVs during labour. 

Although some communities are attempting to tackle stigma, the report states that stigma – and even active discrimination – at the senior levels of government and in the health ministry remain prevalent and go unpunished. In addition, the report said, only a small proportion of orphans and vulnerable children are reached with care and support services.  

The report also said that only about 20% of the estimated 182,200 HIV-positive children are on ARVs.

In Ethiopia, current interventions are largely focused on to the general population. Some people have called for a more targeted approach in the fight against HIV/AIDS in Ethiopia.

"The government has launched a vigorous campaign to fight HIV, but now it is important to target specific groups among whom the epidemic is raging," Desmond Johns, UNAIDS country director for Ethiopia, said in an article written by IRIN, a UN news service. "High testing numbers mean little unless you are testing people at risk, such as commercial sex workers."

According to the Global Fund website, to date $1.8 billion in grants have been approved for Ethiopia, making it the largest Global Fund recipient.

The International Council of AIDS Service Organizations (ICASO) has released a guide on applications under the new funding model (NFM). The guide targets civil society and focuses primarily on standard applicants (i.e. applicants that are not involved in the transition phase but that may apply when the NFM is fully rolled out, likely at the beginning of 2014).

The guide describes the role of civil society in preparing for the eventual application, and in participating in the country dialogue and the concept note development process. It includes a grant application preparedness checklist. It also includes a section on selecting community sector representatives who will participate in the applications process.

The guide, titled “Civil Society Global Fund Application Preparedness Guide,” is available on the ICASO website here.

In a move that had been expected, the World Health Organization has issued new guidelines calling for antiretroviral treatment to be initiated when CD4 counts fall to 500 or less.

Dr Nafsiah Mboi, the new Board Chair, and Mireille Guigaz, the new Board Vice-Chair, took over from the outgoing Chair and Vice-Chair at the close of the Board meeting in Sri Lanka.

New versions of the application materials for early applicants are available on the Global Fund’s website.

In an audit of Global Fund grants to Zimbabwe, the Office of the Inspector General says that there are several funding gaps in the HIV programmes that will disrupt life-saving interventions and other key programme activities if they are not addressed. The OIG also said that major improvements are needed in the management of the grants.

When the Board approved $13 million in malaria interim applicant funding for Mozambique, it also approved $72 million in renewal funding for two existing malaria grants. A large portion of the funding will be used to scale up malaria prevention.

The Global Fund Board has approved $38.2 million in funding for Phase 2 of a Round 9 health systems strengthening grant to Tanzania. The GAC said that this grant represents a strategic investment with the potential to enhance health systems and to improve health outcomes for the three diseases.

Phase 2 funding in the amount of $2.9 million has been approved for a TB grant to Ecuador. The grant is being managed by Care Ecuador.

Rwanda has received a two-year extension to an HIV grant. The Global Fund Board awarded $151 million in funding based on recommendations from the Grants Approvals Committee and the Technical Review Panel. 

This is an issue of the GLOBAL FUND OBSERVER (GFO) Newsletter.

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Author: Article 5: Lídice Lopez (lidilt@hotmail.com), GFO regional correspondent for Latin America and the Caribbean; Article 9: Karanja Kinyanjui (karanja.kinyanjui@aidspan.org), Aidspan’s Senior Editor. All other articles: David Garmaise (david.garmaise@aidspan.org), GFO Editor.

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