COUNTRY COORDINATING MECHANISM Draft version COUNTRY COORDINATING MECHANISM Evolving CCMs to align with the Global Fund Strategy 30 May 2017 Geneva, Switzerland  This document is part of an internal deliberative process of the Global Fund and as such cannot be made public.

Objectives Confirm the vision and strategic topics for CCM evolution Review what we know about CCMs today, including how they are performing Analyze factors that impact CCM and grant performance Agree on next steps, including modalities for CCM and Board / Committee consultations

CCM evolution roadmap Today Now - May 2017 June 2017 – December 2017 Focus today Now - May 2017 June 2017 – December 2017 January 2018 – March 2018 Diagnose and assess current state Develop vision and evolution pathways Create detailed implementation plan I II III I.1 Define ecosystem Outline partner’s roles Define engagement plan II.1 Confirm vision Confirm CCM vision, guiding principles and key enablers III.1 Develop rollout plan Define strategy rollout roadmap III.2 Prepare rollout Change guidance documents Update training material Prepare deployment changes Prepare monitoring tools I.2 Identify data sources & commence compilation Collect quantitative and qualitative data sources Analyze data Define trends & learnings II.2 Develop evolution pathways and targeted models Define portfolio segmentation (targeted models) and evolution pathways Consult with internal and external stakeholders, including CCM members, Board committees and constituencies I.3 Establish portfolio baseline Define which change should come with new GF Strategy (COE, STC, RSSH, ITP….) II.3 Articulate benefits of approach Estimate feasibility and benefits of the proposed models and pathways Prioritize activities and estimate costs Communicate and align strategy with stakeholders via change and stakeholder management IV

Content Confirming Vision for CCMs Understanding CCM Structure 1 Confirming Vision for CCMs 2 Understanding CCM Structure 3 Review of CCM performance 4 Correlation with better CCM and grant performance 5 Next steps: consultations and work planning

CCM Definition from Global Fund Framework Document From the Global Fund Framework Document (Section VI. Chapter B): “..Coordination Mechanism at Country Level..” The Global Fund will work with a country coordination and partnership mechanism that should include broad representation…The mechanism should be at the highest national level …. It should preferably be an already existing body. A senior government official should in most cases chair the mechanism... Based on the CCM Guidelines, CCMs perform five core functions: 1. Coordinate the development and submission of national request for funding 2. Nominate the Principal Recipient 3. Oversee implementation of the approved grant 4. Approve any reprogramming requests 5. Ensure linkages and consistency between Global Fund grants and other national health and development programs

Evidence of scope Stakeholders Review of the qualitative information Available literature has been reviewed and aggregated into the overall analysis Source # Title Evidence of scope CCM Evidence of scope Stakeholders Year Bruce and Dickinson 3 Perspectives Integrating Country Coordinating Mechanisms 28 n/a 2010 AAI 13 Who is really affecting the Global Fund decision making processes 7 95 2012 14 Who is really affecting the Global Fund decision making processes QUANT GMS 16 Strenghtening CCM Oversight 24 200 17 GMS Technical Report Oversight-Dashboards ICASO 4 Effective CCMs and the Meaningful Involvement of Civil Society and Key Affected Populations 2013 12 Participate in CCMs 90 TERG Thematic Review of the Global Fund in Fragile States 19 2014 10 CCM Speak 91 11 The Civil Society Priorities Charter GF /ICASO 6 CCM Key Affected Population and People Living with the Diseases Engagement Initiative Pilot 50 2015 OASYS 9 Document de Capitalisation d'Experiences Dialogue Pays 100 OIG 1 CCM OIG Audit 120 800 2016 GIZ / Global Fund 2 CCM study 5 More than a seat at the table France Germany Switzerland 8 CCM Position Paper Switzerland Germany France Global Fund 15 Publication key populations 60

Vision for CCMs and key themes emerging from discussions Recent analyses, especially “OIG Audit on CCMs” and “Country Presence” paper, confirm overall CCM model is still “fit for purpose”. It has to evolve rather than being replaced. Key themes emerging from the consultations and literature review CCMs should be differentiated, there is a need to outline different models and their characteristics and to guide CCMs accordingly: Oversight function should be clarified and professionalized Focus on PLWD and KAP quality engagement and consider how they could be local watchdogs. Transform CCM Secretariat to be more effective and efficient. Remove duplications/strengthen coordination with other groups. Think beyond Global Fund for CCMs (resource mob, sustainability..)

CCMs can play a key role in the new Global Fund Strategy Results from March CCM Working Group Meeting a Ensure Multi-sectorial engagement Encourage cross- disease cooperation Envisage more professionalized Oversight Committee Strengthen Networks of people living with the disease Propose Smaller CCMs: in certain countries (COEs) Advocate to have KAPS & CS part of transitioning plans b c f d e MAXIMIZE IMPACT AGAINST HIV, TB AND MALARIA Consider the skill and expertise required as CCM members Link CCMs with other broader coordination platforms Include Private Sector as can be a fundamental contributor for this goal a b c a Focus on meaningful KAP engagement Simplify the current tools to ensure accountability Diversify CCM model (e.g. sub-KAP committee) Include faith-based communities How should CCMs evolve to deliver on strategy? b BUILD RESILIENT & SUSTAINABLE SYSTEMS FOR HEALTH PROMOTE & PROTECT HUMAN RIGHTS AND GENDER EQUALITY c d MOBILIZE INCREASED RESOURCES a Mobilize resources beyond the Global Fund. Suggest participation of Minister of Finance Differentiate processes inside the Global Fund Encourage alignment and harmonization Diversify CCM tasks b c d e

Content Confirming Vision for CCMs Understanding CCM Structure 1 Confirming Vision for CCMs 2 Understanding CCM Structure 3 Review of CCM performance 4 Correlation with better CCM and grant performance 5 Next steps: consultations and work planning

This section shows information on how CCMs operate today Key areas to understanding CCMs Funding amounts and cost categories 3 1 Composition and number of members 2 4 Types of Leadership CCM CCM Secretariats

CCM size varies but most have >40% CS members 1 CCM size varies but most have >40% CS members Number of Members Average Percentage of Members Average Civil Society membership is about 50%, which is 10% more than the minimum set by the Eligibility requirement. CCM membership ranges from 5 (Solomon Islands) to 39 members.

2 Majority of CCM chaired by government official As per Framework Document “a senior government should in most cases chair the mechanism” Chair: Gov Other Note: As per Eligibility Requirement 5, the CCM elects its Chair and Vice-Chair(s) from different sectors and also follows good governance principles of periodic change and rotation of leadership

3 CCM / RCM funding has increased over the past 4 years Funding averaged US$90k / year for CCMs and US$180k / year for RCMs Disbursement Amount 2016 disbursements were US$11,411,018 (US$790,036 for RCMs and US$10,620,982 for CCMs) Steady pressure on CCM funding over time, driven largely by increase in number of RCMs

Variance of CCM budgets in differentiated portfolios 3 Variance of CCM budgets in differentiated portfolios USD on Average Average Percentage High Impact and COE have the biggest budgets. Human resources represent about 33% of the budget. Second biggest category is about consultations

CCM Secretariats are between 1-3 people 4 CCM Secretariats are between 1-3 people Average HR Positions in CCM Secretariat Only GF funds, others is not quantified here (not available). High Impact CCM often have co-funded position by others (Government, Partners…)

How are CCM Secretariats being assessed? 4 How are CCM Secretariats being assessed? As part of the new CCM funding policy, all CCM Secretariats are assessed annually (by both CCMs and GF) This started September 2016 and will influence CCM funding disbursements beginning September 2017

Content Confirming Vision for CCMs Understanding CCM Structure 1 Confirming Vision for CCMs 2 Understanding CCM Structure 3 Review of CCM performance 4 Correlation with better CCM and grant performance 5 Next steps: consultations and work planning

CCM performance is measured across 18 dimensions ER 3: Oversight function ER4: Representation of affected communities ER5: Transparent election process ER6: Conflict of interest Oversight Plan KAPs are represented Selection of CS members CoI Policy 1 8 11 15 Oversight Body has 4 core skills PLWDs are represented 40% are CS members CoI Declaration forms 2 9 12 16 Election of Oversight Body Gender Equality CS Engagement plans Mitigation of CoI 3 10 13 17 Oversight Visits Rotation of Chair & Vice-Chair CoI does not exceed 1 member per constituency 4 14 18 Oversight Body meets with PRs 5 CCM takes corrective action CCM shares oversight results 6 7

Performance improved since 2014 but still lags in Civil Society engagement and sharing oversight results The most improved indicator is on demonstrating the mitigation of CoI issues in CCM meeting minutes.

Oversight function - indicators Average performance for all CCMs for ER3 # Eligibility Requirement 3: Overseeing program implementation and having and oversight plan 1 ER A The CCM has an oversight plan which details specific activities, individual and/or constituency responsibilities, timeline and oversight budget as part of CCM budget. 2/3 ER B (2 & 3) The CCM has established a permanent oversight body with adequate set of skills and expertise to ensure periodic oversight. 4 ER C The oversight body (OB) or CCM seeks feedback from non-members of the CCM and from people living with and/or affected by the diseases 5 MS D The oversight body conducts oversight activities to discuss challenges with each PR and identifies problems, potential reprogramming and corresponding reallocation of funds between program activities, if necessary. 6 MS E The CCM takes decisions and corrective action whenever problems and challenges are identified 7 MS F The CCM shares oversight results with the Global Fund Secretariat and in-country stakeholders quarterly through the process defined in its Oversight Plan. Indeterminate Compliant Non Compliant High Impact CCMs do better due to increased partner engagement 0: non-compliant 1: indeterminate compliant 2: fully compliant

Representation of affected communities - indicators Average performance for all CCMs for ER4 # Eligibility Requirement 4: Document the representation of affected communities 8 ER G The CCM ensures adequate representation of key affected populations taking into account the socio-epidemiology of the three diseases. 9 ER H The CCM ensures adequate representation of PLWD, taking into account the socio-epidemiology of the three diseases. 10 MS E The CCM has balanced representation of men and women (the Global Fund Gender Equality Strategy clarifies how women and girls are key affected groups in the context of the 3 diseases). Fully Compliant New indicator Indeterminate Compliant Non Compliant In 3 years only KAP representation (new requirement) has reached a satisfactory level, in terms of “seats”. 0: non-compliant 1: indeterminate compliant 2: fully compliant

CCM survey on country dialogue shows high level of satisfaction Please rate your level of engagement with the country dialogue: N=561 2% 48% 43% 7% Strongly Engaged Moderately Engaged Rarely Engaged Not Engaged I felt free to express my views N=552 7% 4% 44% 45% 1% I felt prepared to participate and add value to the funding request development 7% 4% N=551 37% 51% 1% 5% Those coordinating country dialogue actively reached out to civil society groups and key populations 42% 42% 9% N=555 3% The country team provided good support to country dialogue and the funding request preparation process 7% N=551 32% 50% 8% 3% Source: Participant Survey As of 09 May 2017 Strongly Agree Agree Disagree Strongly Disagree Do Not Know Note: Includes Window 1 only 84% of respondents agreed that civil society and key populations were engaged in the Country Dialogue process

Transparent election process - indicators Average performance for all CCMs for ER5 # Eligibility Requirement 5: Ensure representation of non-governmental members through transparent and documented process 11 ER J All non-governmental constituencies represented on the CCM selected their representative(s) on their own, through a transparent and documented process. 12 MS K CCM membership comprises a minimum of 40% representation from national civil society sectors. 13 MS L CCM has clearly defined processes of soliciting inputs from and providing feedback to their constituencies that selected them to represent their interests in the CCM 14 MS M The CCM elects its Chair and Vice-Chair(s) from different sectors (government, national civil society and development partners ) and also follows good governance principles of periodic change and rotation of leadership according to CCM by-laws. Fully Compliant Indeterminate Compliant Non Compliant Quality of CS/PLWD/KAP engagement (#13) is lagging behind for all portfolios. This is the least performing indicator. 0: non-compliant 1: indeterminate compliant 2: fully compliant

Conflict of interest - indicators Average performance for all CCMs for ER6 # Eligibility Requirement 6: Develop, publish and follow a policy to manage conflict of interest that applies to all CCM members, across all CCM Functions 15/16 ER N (15 & 16) The CCM has a conflict of interest (CoI) policy with rules and procedures to avoid or mitigate CoI5, and CCM members sign a CoI declaration form. 17 ER O CCM meeting minutes demonstrate that CCMs follow the procedures to prevent, manage and mitigate CoI. 18 MS P To guarantee effective decision making, the CCM ensures that the number of members in the CCM with CoI does not exceed 1 person per constituency (excluding Ex-Officio Members with no voting rights). Fully Compliant Indeterminate Compliant Non Compliant More to be done in terms of COI implementation. High Impact are doing slightly better. 0: non-compliant 1: indeterminate compliant 2: fully compliant

Secretariat conducted an analysis to find how CCMs clustered by performance Percentage (Avg) Score CCM Performance Using a K-means method of clustering* on the 18 performance indicators, we have successfully created two distinct groups of CCMs: Higher Performing CCMs CCMs with Performance Issues *An algorithm randomly chooses “k” points (“centers”) among n observations, and create clusters around them by assigning each of the (n-k) remaining observations to whatever center they are closest to. Then once each observation is assign, the algorithm recalculates each center as the mean point of the group and repeats the process until a stable number of clusters is reached.

Clustering results in two distinct performance groups

15 CCMs across regions account for most low performance Higher performing CCMs CCMs with performance issues Belize Central African Republic Egypt Kyrgyzstan Lesotho Mauritania Namibia Nepal Nigeria RCM Abidjan-Lagos Corridor Organisation Romania Sao Tome and Principe Solomon Islands Sri Lanka Yemen CCMs with performance issues These CCMs should be major focus of improvement.

This is correlated to low performing CCMs in COEs countries : COE country (not all are plotted) There is a strong correlation between low performing CCMs and COE. Those countries have difficulties to implement the CCM model. 0% 100% COEs will need differentiated approach.

Content Confirming Vision for CCMs Understanding CCM Structure 1 Confirming Vision for CCMs 2 Understanding CCM Structure 3 Review of CCM performance 4 Correlation with better CCM and grant performance 5 Next steps: consultations and work planning

Analysis: What correlates to CCM performance? To enhance CCM performance, we need to answer two key questions: What factors correlate to improved CCM performance that GF can influence? Does stronger CCM performance correlate to better grant performance? The Secretariat conducted analysis to answer the questions above: Regression analysis based on country, grant and CCM characteristics (independent variables) and CCM and grant performance (dependent variables) The analyses help us identify correlations but cannot prove causation Based on the analysis, we found that: CCM performance has a small but positive correlation with grant performance Stronger CCM performance is correlated with several factors Global Fund can influence (amount of CCM funding, turnover of CCM members and size of CCM)

CCM/Grant Performance Assumptions: Correlation Chain Country characteristics (income level, country risk, size, continent, etc) GF funding characteristics (number of grants, total amount invested, etc) CCM characteristics (size, turnover, GF funding, etc) Assumption: setup of CCM impacts its performance Grant performance (rating, indicator achievement, etc) CCM performance (EPA scores, functioning level, etc) Assumption: well performing CCM => well performing grants

CCM/Grant Performance Assumptions: Methodology We built statistical models to test each of the two assumptions, controlling for other effects (country or funding characteristics) If these assumptions are verified, it means that: We may improve the performance of CCMs by acting on their setup or funding; We may improve the performance of grants by ensuring CCMs are well functioning Assumption: setup of CCM impacts its performance Assumption: well performing CCM -> well performing grants

Level of CCM Functioning Well Performing Grants Factors correlated to grant performance rating Level of CCM Functioning Total Amount Signed +10’000’000 USD Limit is USD 335’443’038 +1 Level + 3.7% + 7.4% Total Population GDP per capita +1000 USD + 1.56% - 6% +10’000’000 Well Performing Grants

Quantitative assessment Factors correlated to EPA Quantitative assessment scores CCM Funding Envelope +100’000 USD Increases in CCM Funding related to increase in performance – up to USD 196,000 Number of Grants + 8.75 Turnover +100 Days +1 Grant + 5.29 + 13.43 EPA Less turnover of CCM members related to higher performance Number of grants increases EPA score up to a limit of 6 grants Non Compliant Fully Compliant 100 Quantitative assessment

Total Amount Signed Grants Qualitative assessment EPA Factors correlated to EPA Qualitative assessment scores Total Amount Signed Grants Number of Members + 10% COE + 6.6% +1 Member - 63% + 2% Increase in number of members (up to 28) related to higher performance COE strongly decreases the level of functioning Qualitative assessment EPA

Content Confirming Vision for CCMs Understanding CCM Structure 1 Confirming Vision for CCMs 2 Understanding CCM Structure 3 Review of CCM performance 4 Correlation with better CCM and grant performance 5 Next steps: consultations and work planning

Key Next Steps Prepare materials for Strategy Committee Meeting Develop diffentiated pathways for CCMs Finalize approach to consultations with CCMs and Board / Committee members Conduct consultations to determine key activities for each type of CCM Prioritize activites and estimate cost of implementation

Phase II will focus on determining differentiation for CCMs Models Characteristics COE Linked to potential emergency response coordination group Lightweight (max 10 members) …… Recognizing the different realities, it is critical to differentiate CCMs and to guide them in their relevant transformations. Small Countries CCM Lightweight Conflict of interest is unavoidable …. Current CCM implementations High Impact CCM Strong partner’s presence Oversight is professionalized …. Diversify resource mobilization Consider MoF presence …. Transition CCM …… : Pathway to adapt (activities)

Illustrative: Thematic areas emerging from analysis Model Sub-Model GF relevance Oversight Set-up/ Composition Leadership/ Engagement Conflict of interests Integration/ Coordination Capacity tech. Support COE Civil War/natural disaster Bare Minimum Small-sized Easy to control Chronic instability Minimum Medium-sized Transition 3 years GF is highly relevant Focus on transition … GF is not very relevant 6 years Normal 9 years …. Small countries Impossible to control High Impact Best Practice MOF, CCM anchored powerful Minis. As-is Standard CCM Efficient Medium GF relevance is calculated as: GF Investments / ALL Diseases investments

Different ‘Governance’ Roles for CCMs - Today Always - The CCM operates using ‘good governance’ practices. - The CCM coordinates Global Fund activities in country. - The CCM coordinates all international health projects in country (e.g. Myanmar). - The CCM is the governing body for all HIV/AIDS, Tuberculosis and Malaria activities in country (e.g. TBC). - CCMs are part of the Global Fund governance model: are playing an active role in Board committees as “CCM members” (rather than individuals or representing a donor/implementing country/organization). Always Sometimes (if CCM is not GF specific, country level decision) Integration* Rarely (if CCM functions are fulfilled by existing body, country level decision) No unless the Board decides otherwise * GF and partners are supporting countries who want to assess this option.

Gantt chart / Progress work plan GF Sec. and CCM Working group GF Secretariat Strategy Committee Deadline to provide SC material Board today 2017 2018 Phases May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Phase 1 – Diagnose and assess current state Define eco-system, engagement plan Analyze data and define learnings Phase 2 - Develop vision and evolution Confirm CCM Vision Define portfolio segmentation + activities Consult with CCM members Consult with Board committees and constituencies Develop high level plan, Prioritize Phase 3 – Create implementation plan Develop rollout plan Prepare rollout Board level documents approved Consultation with GF Sec. and CCM Working group Second week of September Status update to Strategy Committee on “Work stream II” October, 10th – 13th Consultation with GF Sec. and CCM Working group June, 1st Status update to Strategy Committee on “Work stream I” June, 21st - 24th Board update (optional) November, 14th – 16th Consultation with GF Sec. and CCM Working group Mid-Feb SC “Work stream III” TBD Board DP May ‘18

Finding the most appropriate way to consult CCMs Available options to consult CCM Members (mutually exclusive or combination): Online survey Phone interviews Regional CCM workshops (EN-Africa, FR-Africa, Asia, EECA/LAC…?) NB: can also use them for ITP-T/Code of Conduct consultations Other? Considered period: July to mid-September

Finding the most appropriate way to consult Board Constituencies Available options to consult Board constituencies: Online survey Phone interviews Joining the Regional CCM workshops Other? Considered period: August to mid-September

Backup materials

CCMs definition from GF Framework Document From the Global Fund Framework Document (Section VI. Chapter B): “..Coordination Mechanism at Country Level 1. The Global Fund will work with a country coordination and partnership mechanism that should include broad representation from governments, nongovernmental organizations, civil society, multilateral and bilateral agencies and the private sector. The mechanism should be at the highest national level responsible for national multi-partner and multisectoral development planning. It should preferably be an already existing body. If no appropriate coordinating body exists, a new mechanism will need to be established. Where public-private partnerships do not exist, the Global Fund may support alternative partnerships among nongovernmental organizations and the private sector. 2. The Country Coordinating Mechanism will be the focus for program accountability, depending on the Board’s decisions regarding overall Global Fund accountability and fiduciary issues. 3. A senior government official should in most cases chair the mechanism. Where agreed upon among the partners, any member of the mechanism can chair it. 4. The role and function of each player within the partnership of the mechanism will be agreed upon by the mechanism, safeguarding equity and transparency among the partners. 5. The role of the United Nations agencies, multilateral and bilateral agencies and other development agencies in the mechanism should be country partnership-driven and reflect the roles of these partners in AIDS, TB, and malaria programs in-country. The country partners may want to identify a "Lead Support Agency", either bilateral, multilateral or civil society to support the preparation of proposals and undertake any other support as requested by the Country Coordinating Mechanism. ….”

CCM Performance : Model 1 per Indicators

CCM Performance : Model 1 per Indicators (cont’d)