Lessons learned from efforts to strengthen CCMs

CCMs: The Global Funds model for promoting transparency, accountability and multistakeholder involvement By establishing Country Coordinating Mechanisms CCMs as a required entry point for countries wishing to access funding, the Global Fund to fight AIDS, Tuberculosis and Malaria has sought to put into practice the principle, long held in the movement to fight AIDS in particular, of greater involvement of people directly affected in programs that concern them. In the ten years of its existence, the Global Fund has gradually strengthened the requirements related to the proportion of civil society representatives on CCMs, the processes by which members are selected, and to the management of conflicts of interest for CCM members who are also involved in implementation of Global Fund programs. The Global Fund continues to turn down requests for funding from countries with CCMs that do not meet the criteria, and is currently developing an enhanced performance framework, which will aim to ensure that as well as fulfilling basic eligibility requirements, CCMs will play a stronger role in overseeing programs. Few if any donors providing funding at such a large scale have comparable policies aimed at promoting transparency, accountability and multistakeholder involvement, with a view to increasing the impact of their programs. Efforts to make CCMs more effective: what has worked Country actors from government and civil society, technical partners, and advocacy and technical support organizations have invested considerable effort in supporting CCMs to meet the eligibility criteria and to coordinate and oversee Global Fund grants at country level. ICASO, through the CSAT (Civil Society Action Team) initiative, has itself been involved in CCM strengthening work since 2007, through three modes: guidance to country-level civil society organizations on how to organize and advocate as a sector within the HIV response (for instance, through the Coordinating with Communities guide1); short-term training and technical support in response to requests for capacity building or crises within CCMs; and structured, ongoing financial and technical support designed to strengthen community sector advocacy and communications related to the Global Fund at country level. Through these efforts, a number of strategies have emerged that have proved useful in improving community sector engagement in CCMs, such as: Support to transparent election processes for community sector CCM members, along with clarification of roles and improved rotation and alternate member policies, and development of CCM charters. Also includes training and orientation for CCM members. Establishment of strong, visible community sector focal points, which are not necessarily members of the CCM themselves but who can play the role of ensuring communication and

Available in multiple languages in the following locations: http://www.icaso.org/files/coordinatingwith-communities-book-a; http://www.icaso.org/files/coordinating-with-communities-book-b; http://www.icaso.org/files/coordinating-with-communities-action-cards; http://www.icaso.org/files/coordinating-with-communities-workshop-facilitation-notes 1

consultation with the broader sector; regular information sharing through newsletters, websites and blogs. Availability of advice and support from the Global Fund Secretariat. This support has been primarily provided through the now disbanded civil society team, and it is unclear how such support will be provided under the new Secretariat configuration. Support to broader civil society convening at national level, for instance in Jamaica the Civil Society Forum of Jamaica2 which now includes over 100 agencies island-wide working with people living with HIV and key affected populations, including women, people with disabilities, and people who inject drugs. Linking CCM work with broader civil society advocacy, for instance in Cameroon, Positive Generation3 has targeted CCM members as one of the audiences for the data generated from its community level treatment access monitoring work, using access to the CCM to create awareness of problems in treatment access at local level, both in Global Fund supported projects and in those supported by other funding sources. Persistent challenges in community sector engagement in CCMs Although there have been clear improvements in the composition and functioning of CCMs in many countries, civil society organizations, and key population organizations in particular, continue to report that they have little or no impact within CCMs. The recent ITPC-ICASO report, Global Fund Country Coordinating Mechanisms: a Prescription for Change in a Time of Peril4, describes a number of common problems still faced by CCMs: limited capacity of civil society organizations to operate effectively within the CCM environment; poor communication between CCM members and the constituencies they represent; continued non-transparency in member selection; lack of meaningful involvement of key populations; and continued domination of CCMs by government representatives. ICASOs experience of working with CCMs, and with national civil society actors in general, suggests that the fact that the community sector continues to face these challenges needs to be understood as part of broader national contexts, for instance: Legal frameworks and policies in the country, in particular those that marginalize or criminalize populations affected by AIDS, tuberculosis and malaria, or that limit the role of civil society. The range of other forums where decisions and policies on AIDS, tuberculosis and malaria are formed including national strategy and policy planning processes, but also including informal processes where senior government officials, donors and technical agencies are influential. The fact that CCMs are not policy making entities in their own right, but that they are made up of individuals each of whom has an institutional position or identity, and some of whom have far more institutional power than others. (Experience has shown, for instance, that where community sector actors have successfully influenced CCMs, this has often required a
2

The Civil Society Forum of Jamaica is a local coalition advocating for the greater inclusion of civil society organisation in decision making in the Jamaican health sector.http://www.cvccoalition.org/downloads/CSFbooklet.pdf 3 Positive Generation is a grass roots network of people living with HIV based in Yaound, Cameroon (http://camerounaids.org/). 4 http://www.csactionteam.org/?file=175

considerable amount of preparatory work with individual CCM members in advance of any CCM decision). The artificial nature of civil society and key population group constituencies, and the expectation or requirement that civil society organizations should have common positions or agreements on issues related to AIDS, tuberculosis or malaria while the reality is that organizations from civil society often have divergent and even antagonistic viewpoints. The generally marginalized status of the community sector and the lack of recognition of the roles it can play in implementing and monitoring programs. In other words, although in many countries CCMs provide an entry point for community sector organizations to engage with policy and decision makers, the ability of the sector to have an influence is to some extent determined by the structures that exist outside of the CCM. In addition, the tendency of CCMs to focus on relatively abstract concepts such as grant performance indicators, spending rates, and CCM and PR adherence to Global Fund conditions, often leaves little space for representatives of affected communities to assess and raise practical problems faced in the delivery of programs despite the fact that these are the issues that community sector representatives are uniquely qualified to comment on. Community sector organizations often avoid speaking out about problems as they feel it may jeopardize their relationships with PRs and other CCM members. To make matters worse, when community sector representatives do not provide input, they are seen as nave or lacking relevance and this gives a negative perception of their role. Toward a more comprehensive approach to CCM support The conclusion that ICASO draws from its experience, and from its understanding of the experiences of other organizations involved in CCM support work, is that the standard model of CCM strengthening should be accompanied by efforts to strengthen civil society convening and advocacy more broadly. It is also essential that CCMs provide a space for discussion of the issues that are most relevant to community sector actors. ICASO offers a number of recommendations that should be considered by community sector actors and their supporters in taking forward this important work: Continue to provide core support to community sector engagement in CCMs: support to elections, training on roles, and communications in particular. The provision of financial support to a national level community sector organization not necessarily a CCM member to act as communications facility for the sector is also a sound investment. Enable convening of the community sector beyond the specific context of the Global Fund, so that plans for advocacy and engagement with the CCM can be developed based on the broader agendas of the sector. At the same time, the community sector should not be required to adopt consensus positions on every issue the diversity of views within the sector should be acknowledged and accepted. Enable the sector to effectively assess progress of their advocacy engagement work, to understand what can and cannot be achieved through CCM-focused work, and to develop plans to advocate beyond the CCM where necessary.

 Support good quality community level monitoring of AIDS, tuberculosis and malaria programs, including of aspects related to stigma, human rights and gender equity, so as to provide reliable, credible data to inform advocacy within CCMs and other relevant forums. Enable CCM members in particular those from the community sector to define what the CCM should monitor and how, rather than focusing only on top-level grant data and periodic site visits (such visits cannot be expected to provide a reliable picture of overall program performance). Ensure national networks are linked to regional and global networks, to ensure the flow of information and the provision of additional technical support and mentoring where necessary. Ensure linkages between CCM and other national level activism and advocacy, for instance by using the CCM as a forum for channeling and discussing information about broader national program barriers and failures.