GPR 67281 v2 THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA, AND THE WORLD BANK’S ENGAGEMENT WITH THE GLOBAL FUND —VOLUME 2: APPENDIXES— GLOBAL PROGRAM REVIEW Volume 6 Issue 1 THE WORLD BANK GROUP WORKING FOR A WORLD FREE OF POVERTY The World Bank Group consists of five institutions—the International Bank for Reconstruction and Development (IBRD), the International Finance Corporation (IFC), the International Development Association (IDA), the Multilateral Investment Guarantee Agency (MIGA), and the International Centre for the Settlement of Investment Disputes (ICSID). Its mission is to fight poverty for lasting results and to help people help themselves and their envi- ronment by providing resources, sharing knowledge, building capacity, and forging partnerships in the public and private sectors. THE INDEPENDENT EVALUATION GROUP IMPROVING DEVELOPMENT RESULTS THROUGH EXCELLENCE IN EVALUATION The Independent Evaluation Group (IEG) is an independent, three-part unit within the World Bank Group. IEG-World Bank is charged with evaluating the activities of the IBRD (The World Bank) and IDA, IEG-IFC focuses on assessment of IFC’s work toward private sector development, and IEG-MIGA evaluates the contributions of MIGA guarantee projects and services. IEG reports directly to the Bank’s Board of Directors through the Director-General, Evaluation. The goals of evaluation are to learn from experience, to provide an objective basis for assessing the results of the Bank Group’s work, and to provide accountability in the achievement of its objectives. It also improves Bank Group work by identifying and disseminating the lessons learned from experience and by framing recommendations drawn from evaluation findings. Global Program Review The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank’s Engagement with the Global Fund Volume 2: Appendixes February 8, 2011 Public Sector Evaluations http://www.globalevaluations.org ©2012 Independent Evaluation Group, The World Bank Group 1818 H Street NW Washington DC 20433 Telephone: 202-458-4497 Internet: http://www.globalevaluations.org E-mail: ieg@worldbank.org All rights reserved This volume is a product of the staff of the Independent Evaluation Group (IEG) of the World Bank Group. It is part of an ongoing series that reviews global and regional partnership programs in which the World Bank is engaged as one of the partners. The findings, interpretations, and conclusions expressed in this volume do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. IEG does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of IEG concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Rights and Permissions The material in this publication is copyrighted. IEG encourages the dissemination of its work and permits these reviews to be copied or otherwise transmitted, with appropriate credit given to IEG as the authoring body. How to cite this report: IEG (Independent Evaluation Group). 2012. “The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank’s Engagement with the Global Fund: Electronic Survey Administered to World Bank Task Team Leaders and Global Fund Secretariat in March 2011– Volume 2: Appendixes.� Cover photo: Children stand in a circle at a day school facility in Richards Bay, South Africa. The school is for children who have lost their parents to AIDS or have been affected in some way by HIV. Photo by Brent Stirton, courtesy of Getty Images. ISBN-13:978-1-60244-201-6 ISBN-10: 1-60244-201-0 Independent Evaluation Group Strategy, Communication, and Learning (IEGCS) E-mail: ieg@worldbank.org Telephone: 202-458-4497 Printed on Recycled Paper IEG Mission: Improving Development Results Through Excellence in Evaluation The Independent Evaluation Group (IEG) of the World Bank annually reviews a number of global and regional partnership programs (GRPPs) in which the Bank is a partner, in accordance with a mandate from the Bank’s Executive Board in September 2004. The three main purposes are (a) to help improve the relevance and effectiveness of the programs being reviewed, (b) to identify and disseminate lessons of broader application to other programs, and (c) to contribute to the development of standards, guidelines, and good practices for evaluating GRPPs. IEG does not, as a matter a policy, recommend the continuation or discontinuation of any programs being reviewed. A global or regional program review (GPR) is a review and not a full-fledged evaluation. The preparation of a GPR is contingent on a recently completed evaluation of the program, typically commissioned by the governing body of the program. Each GPR assesses the independence and quality of that evaluation; provides a second opinion on the effectiveness of the program, based on the evaluation; assesses the performance of the World Bank as a partner in the program; and draws lessons for the Bank’s engagement in GRPPs more generally. The GPR does not formally rate the various attributes of the program. Assessing the independence and quality of GRPP evaluations is an important aspect of GPRs in order to foster high-quality evaluation methodology and practice more uniformly across Bank-supported GRPPs. Providing a “second opinion� on the effectiveness of the program includes validating the major findings of the GRPP evaluation. Assessing the performance of the World Bank as a partner in the program provides accountability to the Bank’s Executive Board. In selecting programs for review, preference is given to (a) those that are innovative, large, or complex; (b) those in which the Bank is sufficiently engaged to warrant a GPR, (c) those that are relevant to upcoming IEG sector studies; (d) those for which the Executive Directors or Bank management have requested reviews; and (e) those that are likely to generate important lessons. IEG also aims for a representative distribution of GPRs across sectors in each fiscal year. A GPR seeks to add value to the program and to the World Bank beyond what is contained in the external evaluation, while also drawing upon IEG’s experience in reviewing a growing number of programs. It reports on key program developments since the evaluation was completed, including the progress in implementing the recommendations of the evaluation. A GPR involves a desk review of key documents, consultations with key stakeholders, and a mission to the program management unit (secretariat) of the program if this is located outside the World Bank or Washington, DC. Key stakeholders include the Bank’s representative on the governing body of the program, the Bank’s task team leader (if separate from the Bank’s representative), the program chair, the head of the secretariat, other program partners (at the governance and implementing levels), and other Bank operational staff involved with the program. The writer of a GPR may also consult with the person(s) who conducted the evaluation of the GRPP. Each GPR is subject to internal and external peer review and IEG management approval. Once cleared internally, the GPR is reviewed by the responsible Bank department and the secretariat of the program being reviewed. Comments received are taken into account in finalizing the document, and the formal management response from the program is attached to the final report. After the document has been distributed to the Bank’s Board of Executive Directors, it is disclosed to the public on IEG’s external Web site. Contents Abbreviations and Acronyms ............................................................................................................... vii Appendix A. Review Framework for This GPR of the Global Fund ...................................................1 Appendix B. Timeline of the Global Fund and Related Events in the World Bank and Elsewhere...6 Appendix C. Global Fund: Purpose, Principles, and Results Chain .................................................. 26 Appendix D. Global Fund: Core Structures ......................................................................................... 30 Appendix E. Members of the Global Fund Board............................................................................... 31 Appendix F. Global Fund: Sources and Uses of Funds ...................................................................... 33 Appendix G. Global Fund Five-Year Evaluation: Major Findings, Recommendations, and Program Response .................................................................................................................... 47 Appendix H. Global Fund and World Bank Assistance to the Six Countries Visited ...................... 54 Appendix I. Major Findings from the Six Country Visits .................................................................. 60 Appendix J. World Bank Participation at Global Fund Board Meetings, January 2002 to November 2011 ........................................................................................................................ 79 Appendix K. World Bank Involvement in Global Health Partnerships and Financial Intermediary Trust Funds ......................................................................................................... 82 Appendix L. Overview of the Global Environment Facility and the World Bank’s Roles .............. 84 Appendix M. The World Bank’s Programs in the Health Sector....................................................... 93 Appendix N. IEG Assessment of the Independence and Quality of the Five-Year Evaluation ..... 105 Appendix O. Toward A Common Conceptual Framework for Assessing Country-Level Partnerships ............................................................................................................................. 111 Appendix P. Quality Review of Study Area 3 of the Five-Year Evaluation ................................... 124 Appendix Q. Results of the Electronic Survey of World Bank Task Team Leaders and Global Fund Secretariat Staff................................................................................................. 131 Appendix R. Persons Consulted ......................................................................................................... 154 vii Abbreviations and Acronyms AAA Analytical and advisory activities ACT Artemisinin combination therapy ACT-Africa AIDS Campaign Team-Africa AIDS Acquired immunodeficiency syndrome AMFm Affordable Medicines Facility for Malaria ART Antiretroviral therapy or treatment ARV Antiretroviral drug ASAP AIDS Strategy and Action Plan Service (UNAIDS and World Bank) CAS Country Assistance Strategy CCM Country Coordinating Mechanism (Global Fund) CFP Concessional Finance and Global Partnerships Vice Presidency (World Bank) CHAT Country Harmonization and Alignment Tool (UNAIDS) CPA Country Partnership Assessment CSO Civil society organization DAC Development Assistance Committee (OECD) DFID Department for International Development (United Kingdom) DGF Development Grant Facility (World Bank) DOTS Directly Observed Treatment Short-Course (for tuberculosis) FAO Food and Agriculture Organization FPM Fund Portfolio Manager (Global Fund) FYE Five-Year Evaluation of the Global Fund GAMET Global HIV/AIDS Monitoring and Evaluation Support Team GAVI Global Alliance for Vaccines and Immunization (a global partnership program) GEF Global Environment Facility (a global partnership program) GHAP Global HIV/AIDS Program (World Bank and UNAIDS) GPR Global or Regional Program Review (IEG) GRPP Global and/or regional partnership program HDNHE Human Development Network Health Team HIV Human immunodeficiency virus HNP Health, nutrition and population HSS Health systems strengthening IBRD International Bank for Reconstruction and Development IDA International Development Association IEG Independent Evaluation Group, formerly OED (World Bank) IETF Impact Evaluation Task Force IHP International Health Partnership IHP+ International Health Partnership and Related Activities ITN Insecticide-treated bed nets JANS Joint Assessment of National Strategies (a component of IHP+) LDCF Least Developed Countries Trust Fund LFA Local Fund Agent (Global Fund) MAP Multi-country AIDS Program (World Bank) MDGs Millennium Development Goals M&E Monitoring and evaluation MOU Memorandum of understanding NGO Nongovernmental organization OECD Organisation for Economic Co-operation and Development OIG Office of the Inspector General (Global Fund) PBF Performance-based funding (Global Fund) PEPFAR President’s Emergency Plan for AIDS Relief (United States) PSM Procurement supply management RBM Roll Back Malaria (a global partnership program) SCCF Special Climate Change Trust Fund (GEF) viii SIMU Strategic Information and Measurement Unit Stop TB Stop Tuberculosis Partnership (a global partnership program) SUS Integrated Health Service (Brazil) SWAp Sector-Wide Approach TB Tuberculosis TERG Technical Evaluation Reference Group (Global Fund) UNAIDS Joint United Nations Program on HIV/AIDS UNICEF United Nations Children’s Fund UNITAID United to Aid UNDP United Nations Development Programme UNEP United Nations Environment Program UNFCC United Nations Framework Convention on Climate Change USAID United States Agency for International Development WHO World Health Organization Fiscal Year of the Global Fund: January 1 – December 31 1 Appendix A Appendix A. Review Framework for This GPR of the Global Fund Note: IEG has a general evaluation framework for Global or Regional Program Reviews (GPRs) that has been designed to cover the wide range of global and regional partnership programs (GRPPs) in which the World Bank is involved, encompassing knowledge networks, technical assistance programs, and investment programs. The present evaluation framework was adapted from that framework to correspond with the nature of the Global Fund and the focus of this GPR on the Bank’s engagement with the Global Fund at the country level. The questions in Table A-1 constituted the interview protocol for the six country visits that were conducted. Not all questions were answered during each country visit. Table A-1. Validating the Major Findings of the Five-Year Evaluation of the Global Fund 1. Additionality and Sustainability Additionality  What has been the impact of Global Fund grants on (a) overall health expenditures in the country and (b) expenditures on HIV/AIDS, tuberculosis, and malaria?  Is there any evidence that the presence of Global Fund grants has led to reduced — or increased —health or disease-control commitments by other donors, or reduced government expenditures on health or disease control?  Does it make a difference who receives the Global Fund grants?  Which sources of funds do Principal Recipients find easiest to access and use — from the Global Fund, from other donors (including the World Bank), or from the government? Sustainability  How sustainable are Global Fund–supported activities, especially those involving antiretroviral (ARV) treatment, which needs to be sustained for the rest of a recipient’s life?  To what extent is there good collaboration around shared objectives, including sustaining health outcomes for the three diseases and sustaining country systems?  To what extent are steps being taken today to ensure the long-term sustainability of disease-control programs; for example, by allocating domestic resources and building domestic capacity (institutional arrangements, human resources, and capacity for mobilization and management of funds) to sustain the programs?  In addition to governments, what role are civil society and the private sector playing and contributing to sustaining the benefits arising from activities supported by the Global Fund? 2. Country Coordinating Mechanisms (CCMs) Partnership, Leadership, and Participation  What is the legal status of the CCM? What are its roles and authority in preparation, design, and oversight of Global Fund grants?  To what extent does the CCM represent all legitimate country-level stakeholders in relation to HIV/AIDS, tuberculosis, and malaria control?  To what extent are key donors and technical partners for the three diseases (including the World Bank) active members of the CCM?  Who is effectively running the CCM?  To what extent do Global Fund–supported activities “reflect national ownership and respect country-led formulation and implementation processes�?  Has the drive for inclusion and legitimacy hindered the effectiveness of the CCM? Proposal Preparation  To what extent is there broad participation and power-sharing in decision making?  To what extent has the process for the selection of Principal Recipients been clearly defined, open, and Appendix A 2 transparent?  How does the CCM fit in the overall aid coordination in the country?  To what extent is the CCM contributing to country-led aid coordination based on clear and coherent national health strategies for disease control? Oversight of Grant Implementation  How is the CCM itself being financed? Who pays for administration, and for travel and subsistence costs involved in attending meetings?  To what extent are the communications between the CCMs, Principal Recipients, and Local Fund Agents (LFAs) effectively contributing to grant performance? Conflicts of Interest  To what extent are conflicts of interest — such as CCM members receiving funds from Global Fund grants as Principal Recipients or Sub-Recipients — being managed well and transparently? 3. Country-Level Partnerships Partnering with International Organizations and Bilateral Donors  To what extent are development partners now providing technical assistance to support the preparation and implementation of Global Fund grants? What kinds of assistance?  To what extent is the interface between technical assistance and investments improving? Partnering with Civil Society Organizations  To what extent have the government and donors been proactive in helping to build the capacity of civil society organizations (CSOs) to participate meaningfully in Global Fund activities as CCM decision makers and grant implementers? How much progress has there been? What is the evidence that this is producing results?  To what extent are the inevitable tensions between CSOs and governments being addressed in creative ways for the common good? Partnering with the Commercial Private Sector  What has been the degree and nature of the involvement of the commercial private sector in Global Fund– supported or other disease-control activities in the country such as (a) CCM participation; (b) mobilizing resources, in cash or in kind; (c) grant implementation; or (d) undertaking their own parallel initiatives. 4. Performance-Based Funding (PBF) To what extent are performance-based principles being applied and effectively operating in the country? To what extent is the system working well or completely broken? Why? To what extent are Global Fund agents (CCMs, Principal Recipients, Sub-Recipients, and LFAs) moving toward the goal of PBF? Or are they starting to adopt other approaches to measuring results? What is the nature of the performance contracts — i.e., between the Global Fund and the Principal Recipients — being used in the country in terms of effectiveness and efficiency? Who is responsible for monitoring results and enforcing the performance-based contracts? To what extent are more differentiated approaches to quality assurance being adopted, reflecting existing country-level capacity constraints while still affirming PBF principles? To what extent do local partners find the PBF elements of Global Fund contracts burdensome, and if so, why? To what extent are the Global Fund requirements getting in the way of doing what is effective? 5. Service Delivery, Prevention, and Treatment To what extent have Global Fund grants changed the availability and utilization of services during the last few years? What is the evidence for this? To what extent does the relative emphasis of Global Fund–supported activities on AIDS, tuberculosis, or malaria reflect the needs of the country? If not, why not? To what extent do Global Fund–supported activities represent an integrated and balanced approach covering prevention, treatment, and care and support in dealing with the three diseases? (Global Fund Guiding Principle E) What is the evidence for this? Is there any evidence of effective innovative approaches, supported by Global Fund grants, to prevention or treatment of the three diseases in the country? 3 Appendix A 6. Equity To what extent are disease-control services being provided equitably at the country level? To what extent are marginalized populations being served? 7. Domestic Health Systems In the opinion of the interviewee, what has been the impact (positive or negative) of Global Fund–supported activities on the country’s health systems? To what extent has the focus on fighting the three diseases disrupted health systems? To what extent are we (the country and the donors) managing to do both fighting diseases and building health systems at the same time? In the opinion of the interviewee, does the World Bank have a comparative advantage in strengthening domestic health systems to fill a gap in Global Fund–supported activities? If yes, what is required and what is the Bank doing in this regard? To what extent are promises of greater collaboration among Global Fund partners being reflected at the country level — in practice; in donor dialogue; and, as a minimum, in knowledge and expectations? 8. Risk Management How well is the LFA system working to mitigate financial risks of Global Fund grants not being used for the intended purposes? To what extent is the weak absorptive capacity of domestic health systems or the absence of a comprehensive partnership strategy posing organizational risks to the Global Fund? To what extent are tensions between the Global Fund Secretariat, CCMs, Principal Recipients, and LFAs around the application of country ownership and PBF principles posing operational risks to the Global Fund. To what extent is dependence on the Global Fund for providing treatments for the three diseases posing political risks to the Global Fund? Table A-2. The World Bank’s Engagement with the Global Fund 1. Bank’s Engagement with the Global Fund at the Global Level What are the Bank’s roles in the Global Fund at the corporate level? To what extent do these facilitate or hinder country-level engagement? In what other global health partnerships is the Bank involved? To what extent does this involvement facilitate or hinder country-level engagement with the Global Fund? In what other institutional collaborations is the Bank involved, such as the Global HIV/AIDS Program, the International Health Partnership, and related activities? To what extent do these facilitate or hinder country-level engagement? What other specific efforts have there been at the global level to promote country-level engagement between the World Bank and the Global Fund? What have been their impacts? 2. Bank’s Engagement with the Global Fund at the Country Level What has been the breadth and depth of Bank’s engagement with the Global Fund at the country level? To what extent has the Bank been involved in country-level processes of the Global Fund, or in other country-level activities that have directly or indirectly contributed to the work of the Global Fund at the country level? What factors in relation to the two organizations’ operational models have made it easier or more difficult for World Bank staff or consultants to engage with Global Fund–supported activities at the country level? What has been the Bank’s own support for communicable disease control, health systems strengthening (HSS), and Sector-Wide Approaches (SWAps)? To what extent have these facilitated or hindered country-level engagement with the Global Fund? What are the respective comparative advantages of the two organizations in terms of supporting communicable disease control and HSS at the country level? What changes in the Global Fund and the World Bank would facilitate greater operational engagement at the country level? Appendix A 4 Table A-3. The Independence and Quality of the Five-Year Evaluation of the Global Fund Evaluation Questions 1. Evaluation Process To what extent was the GRPP evaluation independent of the management of the program, according to the following criteria:  Organizational independence?  Behavioral independence and protection from interference?  Avoidance of conflicts of interest? Factors to take into account in answering these questions include:  Who commissioned and managed the evaluation?  Who approved the terms of reference and selected the evaluation team?  To whom the evaluation team reported, and how the evaluation was reviewed?  Any other factors that hindered the independence of the evaluation such as an inadequate budget, or restrictions on access to information, travel, sampling, etc.? 2. Monitoring and Evaluation Framework of the Program To what extent was the evaluation based on an effective monitoring and evaluation (M&E) framework for the program and its activities with:  Clear and coherent objectives and strategies that give focus and direction to the program?  An expected results chain or logical framework?  Measurable indicators that meet the monitoring and reporting needs of the governing body and management of the program?  Systematic and regular processes for collecting and managing data? 3. Evaluation Approach and Scope To what extent was the evaluation objectives-based and evidence-based? To what extent did the evaluation use a results-based framework — constructed either by the program or by the evaluators? To what extent did the evaluation address:  Relevance  Governance and management  Efficacy  Resource mobilization and financial management  Efficiency or cost-effectiveness  Sustainability, risk, and strategy for devolution or exit 4. Evaluation Instruments To what extent did the evaluation utilize the following instruments:  Desk and document review  Consultations/interviews and with whom  Literature review  Structured surveys and of whom  Site visits and for what purpose: for interviewing implementers/beneficiaries, or for observing activities being implemented or completed  Case studies  Other 5. Evaluation Feedback To what extent have the findings of the evaluation been reflected in: a. The objectives, strategies, design, or scale of the program? b. The governance, management, and financing of the program? c. The M&E framework of the program? 5 Appendix A Table A-4. Common GRPP Activities Knowledge, Advocacy, and Standard-Setting Networks 1. Facilitating This includes providing a central point of contact and communication among practitioners communication among who are working a sector or area of development to facilitate the sharing of analytical results. practitioners in the sector It might also include the financing of case studies and comparative studies. 2. Generating and This comprises three related activities: (a) gathering, analyzing, and disseminating disseminating information information, for example, on the evolving HIV/AIDS epidemic and responses to it, including and knowledge epidemiological data collection and analysis, needs assessment, resource flows, and country readiness; (b) systematic assembly and dissemination of existing knowledge (not merely information) with respect to best practices in a sector on a global/regional basis; and (c) social scientific research to generate new knowledge in a sector or area of development. 3. Improving donor This should be an active process, not just the side effect of other program activities. This coordination may involve resolving difficult interagency issues in order to improve alignment and efficiency in delivering development assistance. 4. Advocacy This comprises proactive interaction with policymakers and decision makers concerning approaches to development in a sector, commonly in the context of global, regional, or country-level forums. This is intended to create reform conditions in developing countries, as distinct from physical and institutional investments in public goods, and is more proactive than generating and disseminating information and knowledge. 5. Implementing Rules are generally formal. Standards can be formal or informal, and binding or nonbinding, but conventions, rules, or formal establishing standards involves more than simply advocating an approach to development in a and informal standards and sector. In general, there should be some costs associated with noncompliance with established norms rules and standards. Costs can come in many forms, including exposure to financial contagion, bad financial ratings by the International Monetary Fund and other rating agencies, with consequent impacts on access to private finance; lack of access to Organisation for Economic Co-operation and Development (OECD) markets for failing to meet food safety standards, or even the consequences of failing to be seen as progressive in international circles. Financing Technical Assistance 6. Supporting national- This is more directed to specific tasks than to advocacy. This represents concrete level policy, institutional, and involvement in specific and ongoing policy, institutional, and technical reform processes in a technical reforms sector, from deciding on a reform strategy to implementation of new policies and regulations in a sector. It is more than just conducting studies unless the studies are strategic in nature and specific to the reform issue in question. 7. Capacity strengthening This refers to strengthening the capacity of human resources through proactive training (in and training courses or on the job), as well as collaborative work with the active involvement of developing-country partners. 8. Catalyzing public or This includes improving regulatory frameworks for private investment and implementing pilot private investments in the investment projects. sector Financing investments 9. Financing country-level This refers primarily to physical and institutional investments of the type found in Bank investments to deliver loans and credits (more than the financing of studies), the benefits of which accrue primarily national public goods at the national level. 10. Financing country-level This refers primarily to physical and institutional investments of the type found in Bank investments to deliver loans and credits (more than the financing of studies) to deliver public goods such as global/regional public goods conserving biodiversity of global significance and reducing emissions of ozone-depleting substances and carbon dioxide, the benefits of which accrue globally. 11. Financing global/regional This refers to financing research and development for new products and technologies. investments to deliver global/ These are generally physical products or processes — the hardware as opposed to the regional public goods software of development. Appendix B 6 Appendix B. Timeline of the Global Fund and Related Events in the World Bank and Elsewhere Date Global Fund World Bank Other 1993 Bank publishes the World Development Report 1993: Investing in Health, emphasizing global burden of disease and introducing Disability Adjusted Life Years as a metric for performance. Bank-sponsored research study, Disease Control Priorities in Developing Countries, contributes to increasing international awareness of disease control challenges and opportunities. 1994 Bank publishes World Population Projections 1994– Joint United Nations Program on HIV/AIDS (UNAIDS) 95, including impact of AIDS, immediately before the launched as a partnership to lead and inspire the International Conference on Population and world toward achieving universal access to HIV Development in Cairo. prevention, treatment, care, and support. (September) Better Health in Africa emphasizes health-systems strengthening (HSS) and gives less attention to disease control. 1996 Bank becomes a donor to the International AIDS International AIDS Vaccine Initiative is launched as a Vaccine Initiative, providing support from the Bank’s non-profit public-private product development and Special Grants Program. advocacy partnership. 1997 (September) World Bank HNP (Health, Nutrition, and (June) Communiqué of G8 meeting in Denver points Population) Sector Strategy launched. Strategy out that infectious diseases, including drug-resistant underscores importance of institutional and systemic tuberculosis, malaria, and HIV/AIDS, are responsible changes to improve health outcomes for the poor, for a third of all deaths in the world and states that improve health system performance, and achieve preventing the transmission of HIV infection and the sustainable health sector financing. With a portfolio of development of AIDS are urgent global public health 154 active and 94 completed HNP projects, for total imperatives. cumulative value of $13.5 billion (1996 prices), the Strategy states that Bank has become the largest single source of external HNP financing. Strategy calls for sharpening strategic focus but gives relatively little attention to disease control. 7 Appendix B Date Global Fund World Bank Other (November) Bank releases Development Economics Department policy research study Confronting AIDS: Public Priorities in a Global Epidemic. Study makes the case for government intervention to control AIDS from epidemiological, public health, and public economics perspectives. 1998 (April) Development Economics and Human (June) 12th World HIV/AIDS conference. Development Vice-Presidencies initiate an institution- (November) World Health Organization (WHO), wide AIDS Vaccine Task Force to examine innovative United Nations Development Program (UNDP), the ways to encourage development of an effective and World Bank, and United Nations Children’s Fund affordable AIDS vaccine. (UNICEF) launch Roll Back Malaria (RBM) to provide (November) International Development Association a coordinated approach to reduction of the (IDA) 12th replenishment agreed among donors — prevalence of malaria, ideally by half by 2010; its including nearly 40 countries — permitting IDA credits leadership and secretariat are provided by WHO. for $20.5 billion, over three years. 1999 (June) Bank publishes a new African HIV/AIDS (November) Medicines for Malaria Venture launched strategy, Intensifying Action against HIV/AIDS in as a public-private partnership—with seed money Africa: Responding to a Development Crisis, and from Switzerland, the U.K. Department for establishes its AIDS Campaign Team — Africa (ACT– International Development (DFID), the Netherlands, Africa) in the Office of the Africa Regional Vice- the World Bank, and the Rockefeller Foundation—to Presidents. develop new, affordable malaria drugs and design access and delivery modalities. 2000 (July) Expanding on prior concern with infectious (January) Bank President Wolfensohn addresses (January) GAVI launched at World Economic Forum disease limited to HIV/AIDS, G8 meeting in Japan U.N. Security Council on HIV/AIDS at its first-ever as an alliance of public and private donors hosted by agrees to implement an “ambitious plan� to deal with meeting on a disease, and calls for increased UNICEF to promote and finance vaccines and infectious diseases, notably HIV/AIDS, malaria, and resource allocation to fight a “War on AIDS.� immunizations. tuberculosis, and announces a conference in Japan Bank pledges to substantially increase its financial (March) Ministerial Conference on Tuberculosis And to deliver agreement on a new strategy to harness the support in the fight against HIV/AIDS and other Sustainable Development attended by ministers of G8 commitment. The conference should look to communicable diseases, with an initial commitment of health and finance from 20 of the 22 high-burden define the operations of a new partnership, the areas $1 billion and more resources as national and countries, adopts Amsterdam Declaration on of priority, and the timetable for action. regional programs are developed. FY2000 HNP Tuberculosis and Sustainable Development. Stop (December) Further to the G8 Okinawa Summit, commitment: $1.0 billion. (World Bank Annual Report) Tuberculosis Partnership endorsed. Japan hosts meeting of health experts. Agreement is Bank joins Global Alliance for Vaccines and (February) United States (Clinton Administration) reached that a new funding mechanism to fight the Immunization (GAVI) at inception and provides seeks congressional funding of $4 billion for HIV/AIDS three diseases should be explored. funding from its Development Grant Facility (DGF). and infectious diseases. Appendix B 8 Date Global Fund World Bank Other (July) According to its communiqué, G8 Summit (September) U.N. Millennium Summit adopts what “strongly welcomed the World Bank's commitment to became known as the Millennium Development Goals triple International Development Association (IDA) (MDGs), including to halt by 2015 and begin to financing for HIV/AIDS, malaria, and tuberculosis.� reverse the spread of HIV/AIDS, the scourge of (September) First Multi-Country AIDS Program (MAP) malaria, and other major diseases. is approved by the Board, providing $500 million in (September) European Commission convenes a high- IDA credits for financing HIV/AIDS projects in Africa. level roundtable in Brussels, with WHO and UNAIDS, Bank also earmarks $155 million to fight AIDS in the to design an action program for the European Union Caribbean. to help developing countries confront the growing epidemics of the three diseases. The Commission, WHO, and UNAIDS announce a common stand against HIV/AIDS, malaria, and tuberculosis in the developing world. 2001 (April) U.N. Secretary General’s speech at Abuja (May) After cooperating with the U.N. and others on Global Business Coalition on HIV/AIDS, Tuberculosis, Summit of African leaders calls for African leaders definition of the MDGs, the Bank announces that it will and Malaria formed under leadership of Ambassador and rich countries to commit at least $7–10 billion a join with the U.N. as a full partner to implement the Richard Holbrooke to mobilize the business year to the struggle against HIV /AIDS and other MDGs and put them at the heart of its development community throughout the world in the fight against diseases. He proposes creation of a Global Fund, agenda. the three diseases. dedicated to the battle against HIV/AIDS and other FY2001 World Bank and IDA commitments for HNP (April) African Union Abuja Summit commits African infectious diseases. amount to $1.3 billion. governments to devote 15 percent of their budgets to (May) U.N. General Assembly special session on World Bank Institute launches Leadership Program on the health sector. HIV/AIDS adopts Declaration of Commitment, calling AIDS to build capacity for accelerated implementation (April) Mobilizing action to implement effective nation- for reaching an overall target of annual expenditure of HIV/AIDS programs. ( IEG HNP evaluation). wide programs is focus of attention of 4th Roll Back on the epidemic of between US$ 7 billion and US$10 Malaria Global Partnership Meeting. billion in low- and middle-income countries by 2005 (December) Report of WHO Commission on and supporting the establishment of a global Macroeconomics and Health launched; Commission HIV/AIDS and health fund to finance an urgent and calls for donor assistance for health, coordinated by a expanded response to the epidemic. steering group to be led by WHO and the World Bank, (May) Donors make initial pledges of support to the to increase funding from $6 billion annually to $27 Global Fund: U.S. pledges founding support of $200 billion by 2007 and $38 billion by 2015, with special million; U.K. and France; $300 million; Gates emphasis on scaling up of programs, especially the Foundation, $100 million. fight against HIV/AIDS, tuberculosis, and malaria and (July) With the U.N. Secretary-General, G8 Summit in global public goods for health, including greater Genoa announces launching of a new Global Fund, to funding of research and development. be a public-private partnership, to fight HIV/AIDS, malaria, and tuberculosis. G8 determined to make the fund operational before the end of the year with G8 9 Appendix B Date Global Fund World Bank Other commitments to the Fund of $1.3 billion. G8 calls on other countries, the private sector, foundations, and academic institutions to join with their own contributions — financially, in kind, and through shared expertise. G8 stresses low transaction costs, light governance, and a strong focus on outcomes. (August ) Transitional Working Group formed with Uganda as its chair; Technical Support Secretariat is led by USAID. General organizational guidelines for the fund are defined; World Bank actively engaged, including offer to serve as interim trustee. (December) Last meeting of the Transitional Working Group decides on major structural elements of the Global Fund at the global level. 2002 (January) Transitional Working Group converted into (February) Second $500 million MAP envelope is U.N. Secretary-General Kofi Annan launches Global founding Global Fund Board. Oversight Committee approved. The second MAP allows finance of ART. Health Initiative at the 2002 World Economic Forum drafts Framework Document. Seven country-level African MAP projects are Annual Meeting. The Initiative’s mission is to engage (January ) Global Fund formally created as an approved, including two financed by the first IDA businesses in public-private partnerships to tackle independent Swiss foundation, with total pledges of grants. HIV/AIDS, tuberculosis, malaria, and HSS, but $1.7 billion. First meeting of its Board takes place. World Bank becomes trustee of Global Fund financial communicable diseases figure relatively less U.S. Secretary of Health and Human Services Tommy resources, with responsibility to receive and prominently than non-communicable diseases in Thompson elected chair; operating procedures temporarily invest Global Fund contributions and to Forum. adopted. Swedish International Development disburse them only on instruction from Global Fund. (March) External evaluation of RBM completed, Authority staff member is interim head of Secretariat. (June) Bank Global HIV/AIDS program (GHAP) is finding global spending on malaria has doubled since Working Group on M&E established. launched, and Bank appoints its first Global HIV/AIDS 1998, but slow progress and need for concentrated (February) First call for proposals issued (Round 1). advisor. Global Monitoring and Evaluation Support effort at the country level. (March) Technical Review Panel constituted to review Team (GAMET) is created, housed at the World (June) G8 Summit in Canada adopts Africa Action 400 proposals. Bank, to facilitate UNAIDS cosponsor efforts to build Plan, committing leaders to help Africa combat AIDS country-level M&E capacities and coordinate technical and to strengthen health systems by continuing to (April) Second Board meeting. Former World Bank support. support Global Fund (Chair’s summary). HNP Director Richard Feachem appointed Executive Director; trusteeship agreement with World Bank, and World Bank commitments for HNP during FY02 were administrative agreement with WHO approved; $0.6 $1.4 billion, including $320 for communicable billion in grants over two-year period approved for 36 diseases. More than 30 countries reported to benefit countries; $2 billion in pledges received. LFA from Bank support for tuberculosis control, with 45 arrangements approved. active projects supporting malaria control. ( FY02 World Bank Annual Report) (October) Third Board meeting. Drug procurement Bank Annual Report highlights Bank engagement on Appendix B 10 Date Global Fund World Bank Other policies facilitate large-scale purchase of generic and communicable diseases, specifically including patented medicines by developing countries. HIV/AIDS and tuberculosis, at the country level and in (November) Technical Review Panel reviews 200 international partnerships. proposals from 100 countries (Round 2). First grant agreements signed with Ghana, Tanzania, Haiti, and Sri Lanka. (December) First disbursement of $1 million made 2003 (Jan) Board refines eligibility criteria, focusing on (April) 13th Replenishment of IDA becomes effective (January) The U.S. President's Emergency Plan for countries with greatest need, enabling countries with with three years of funding at $23 billion. AIDS Relief (PEPFAR) launched to fight the global repeated unsuccessful proposals to appeal, and (September) Bank launches Education and AIDS: A HIV/AIDS pandemic, pledges $15 billion over five launches Round 3 grants process. Sourcebook of HIV/AIDS Prevention Programs, which years (2003–08). (March) More than $10 million disbursed. Resource aims to strengthen the role of the education sector in (June) G8 “agrees on measures to strengthen Global mobilization of Global Fund undertaken, aided by the prevention of HIV/AIDS. Fund and other bilateral and multilateral efforts.� G8 nongovernmental organizations (NGOs) working at (September) Bank Annual Report describes its health action plan encourages “those that have not both grassroots and in donor capitals. commitment to MDGs and emphasizes four priority yet done so� to increase their support to “Global Fund (May) Global tender issued for LFA support on a sectors, including HIV/AIDS and health. (IEG HNP and other bilateral and multilateral efforts� to control country-by-country basis. PBF procedures finalized evaluation). Report includes boxed essay on Bank AIDS, tuberculosis, and malaria.� (Chair’s summary after consultation with technical organizations, engagement at country level on HIV/AIDS, and action plan) bilateral agencies, and recipients. tuberculosis, and malaria, summarizing success (December) The 3X5 ("3 by 5") initiative launched by (August) Global Fund and UNAIDS sign variables such as sound public policies, strong health UNAIDS and WHO. Initiative aims to provide three memorandum of understanding (MOU). care capacity, adequate financing, and effective M&E. million people living with HIV/AIDS in low- and middle- Bank/IDA commitments for health and other social income countries with ART by end-2005. (Oct) Board of Directors adopts M&E strategy and services in FY2003 were $3.4 billion, including $1.6 (December) Independent External Evaluation of Stop work program, and decides to form Technical billion for the health sector and $442 million for TB Partnership finds major achievements, including Evaluation Reference Group (TERG), an independent communicable diseases. ( World Bank Annual significant progress against tuberculosis, even in expert group, to (a) advise Global Fund Board and (b) Report) difficult environments. Evaluation also finds strong support the Global Fund Secretariat’s M&E work; nine members appointed by Board of Directors and four ex commitment by partners to continuation, but that officio members. changes in donor funding priorities and establishment of new funding mechanisms such as the Global Fund (Oct) Board approves undertaking a Five-Year have intensified competition for resources and Evaluation (FYE) of Global Fund overall performance created uncertainties on funding flows for the against goals and principles after at least one full grant partnership. Aim of $20–$30 million annual long-term cycle has been completed. FYE to be planned and funding for Global [Tuberculosis] Drug Facility implemented under TERG oversight. Areas for study: appears unrealistic and alternatives were found to be organizational efficiency and effectiveness; needed. effectiveness of the partner environment; and impact of Global Fund on HIV/AIDS, Tuberculosis, and malaria. 11 Appendix B Date Global Fund World Bank Other 2004 (March) Former Japanese prime minister announces Bank HIV/AIDS portfolio at end FY04: (a) (January) Global Fund discussed at Davos World formation of Friends of the Global Fund, Japan, to projects/components in closed projects with $666 Economic Forum. mobilize support there. (Global Fund Annual Report) million in Bank/IDA commitments; (b) $552 million in (January) World Bank and WHO cosponsor first High- (April) At its 8th meeting, Global Fund Board allows active AIDS projects and components; (c) $1,061 Level Forum on the Health MDGs and bring together countries with high drug resistance (15 percent +) to million in active Africa Region MAP operations; and heads of agencies, ministers, and senior officials from purchase artemisinin combination therapy (ACT) (d) $111 million in active Caribbean MAP projects. 17 developing countries (including 9 ministers of drugs (five times more costly than first-line malaria Total: $1,727 million. ( IEG AIDS evaluation) health, finance, economic planning, and local drugs). Total approved grants: $5.9 billion over five Bank Annual report states Bank has committed more government); heads of 11 bilateral agencies; 8 years, $968 million over two years. Board approves than $2.4 billion for HIV/AIDS-related programs since multilateral agencies; and 9 foundations, regional periodic replenishment model for financing Global 1990 and is actively engaged in policy dialogue at the organizations, and global partnerships (subsequent Fund. Global Fund has 51 donor countries, hundreds country level to use Poverty Reduction Strategy meetings include December 2004, November 2005, of private contributors, and received over $7 million in Papers and the Heavily Indebted Poor Country and June and September 2006). pro bono support. (Global Fund Annual Report) Initiative to release funds from debt relief for fighting (April) “Three Ones� principles formulated by Following competitive tender, seven enterprises HIV/AIDS. Bank releases technical guide for decision UNAIDS, Global Fund, and the World Bank in selected to provide LFA services (Global Fund Annual makers on procurement of medicines and related cooperation with others are announced at meeting to Report). supplies. $60 million Treatment Acceleration Project increase coordination on AIDS operations at the is approved, to pilot country-level partnerships for country level: (a) one country strategy; (b) one (June) Global Fund Monitoring and Evaluation Toolkit scaling up treatment. national HIV/AIDS coordinating institution; and (c) one published — developed jointly with WHO, World Bank, UNICEF, UNAIDS, U.S. Agency for (July) Bank releases Battling HIV/AIDS: A Decision- M&E framework; other donors and developing International Development (USAID), U.S. State Maker's Guide to the Procurement of Medicines and countries also participate in meeting. Department, U.S. Department of Health and Human Related Supplies. (April) World Bank, Global Fund, UNICEF, and Services, and the Centers for Disease Control and Clinton Foundation reach agreement that allows Prevention. countries supported by the three donor institutions to (July) Friends of the Global Fight launched in the gain access to ARV drugs and diagnostics at low U.S., to mobilize publicity and support in U.S. (Global prices negotiated by the Clinton Foundation. Fund Annual Report) Cable TV channel starts (June) World Bank, Global Fund, UNICEF, WHO, national advertizing campaign on HIV/AIDS “Stopping UNAIDS, USAID, U.S. Departments of State and AIDS before it Stops the World.� Health and Human Services and Centers for Disease (July) First biennial Partnership Forum in Bangkok Control and Prevention release M&E toolkit for provides voice for 450 participants from Global Fund HIV/AIDS, tuberculosis, and malaria, subsequently constituencies and recommendations are submitted to revised and reissued in 2006 and 2009. Global Fund Board of Directors. (July) 15th International HIV/AIDS conference held in (September) Global Fund launches first media Bangkok. campaign, with newspapers, magazines, TV, and film. (July) U.S. Institute of Medicine panel led by Nobel (September) TERG established; evaluation Laureate economist Prof. Kenneth Arrow discussion paper issued on FYE recommends pooling of malaria drug procurement across countries as means to reduce prices of ACTs (November) Ninth Board Meeting in Arusha — first Appendix B 12 Date Global Fund World Bank Other Board meeting in Africa — includes site visits and and sets the stage for Affordable Medicines Facility participation of three presidents of East African for Malaria (AMFm). countries. Board adopts revised CCM requirements. (December) Headquarters agreement signed with Swiss government giving Global Fund privileges and immunities similar to international organizations. Global Fund press coverage: 3,500 times in main English language media. (Global Fund Annual Report) Total pledges to Global Fund: $5.9 billion; total grant commitments: $3.1 billion in 127 countries. ( Global Fund Annual Report) 2005 (March) First Global Fund replenishment meeting, (January) Rolling Back Malaria: the World Bank (January) World Economic Forum in Davos. WHO, Stockholm, chaired by U.N. Secretary-General Kofi Global Strategy and Booster Program provides UNAIDS, Global Fund, and U.S. present results of Annan and former World Bank Managing Director rationale for initiating five-year “Booster Program� for progress, especially on expanded access to Sven Sandstrom, with participation of 30 countries. malaria control. Program envisages $500–$1,000 antiretroviral therapy (ART). (April) Global Fund Board of Directors elects chair of million in new commitments for malaria control over (February) Paris Declaration on Aid Effectiveness National Commission for HIV/AIDS of Barbados as five years. adopted at OECD meeting emphasizes principles of Global Fund Board of Directors chair. (February) Negotiations on 14th IDA Replenishment recipient ownership of externally funded programs (Spring) Building on recommendations of 1st concluded, for about $35 billion over three years. ( and projects; alignment of donor support with Partnership Forum, regional workshops are initiated Annual Report) recipients’ strategies, institutions, and procedures; for strengthening CCMs. (Global Fund Annual Report) IEG evaluation of Bank HIV/AIDS assistance, harmonization and transparency; managing for Committing to Results: Improving the Effectiveness of results; and mutual accountability of donors and (May) Board committees restructured as per 10th HIV/AIDS Assistance, is released. It finds Bank partners for development results. Board Meeting decision (Policy & Strategy; Finance & Audit, Portfolio, and Ethics Committees) comparative advantage to be building institutions, (April) European Union develops action plan to assessing alternatives, and improving the Confront HIV/AIDS, Malaria and Tuberculosis through (May) U.S. Government Accountability Office performance of national AIDS efforts. Concerning the External Action (2007–11). recommends changes, welcomed by Global Fund, in MAP operations, IEG called for a thorough (June) Following high-level meeting to review global disbursement documentation. (Global Fund Annual assessment of national strategic plans and response to HIV/AIDS sponsored by the U.K., U.S., Report) government AIDS policies as a standard part of and UNAIDS, Global Task Team on Improving AIDS (June) Second Replenishment Meeting; France, individual project preparation. Coordination among Multilateral and International Japan, Australia increase pledges to Global Fund. Bank Annual Report states Bank has committed $2.5 donors, inter alia independent study of comparative (June) Global Fund launches advertising campaign to billion to fighting HIV/AIDS in 67 countries, more than advantages of Global Fund and World Bank and grow grassroots support for Global Fund, in $600 million to tuberculosis control since 1991 in assistance to countries in preparing AIDS strategies anticipation of G8 meeting. more than 30 countries, and summarizes malaria and plans is recommended. (July) Office of Inspector-General established booster program. Report cites launching of Bank (June) Launch of President’s Malaria Initiative in AIDS Media Center Web site with many partners, to 13 Appendix B Date Global Fund World Bank Other reporting directly to Board of Directors (2010 Progress provide journalists in developing countries with a United States includes a pledge to increase U.S. Report) global source for HIV/AIDS news, information, and malaria funding by more than $1.2 billion over five (July) WHO Internal Oversight Office conducts audit analysis and to increase the accuracy, quality, and years to reduce deaths due to malaria by 50 percent and finds no evidence of fraud, misuse of funds, or effectiveness of AIDS-related reporting. in 15 African countries. violation of conflict of interest policies in Global Fund. (November) Bank releases new global World Bank (June) PEPFAR Implementers Meeting, with Global (Aug) Global Fund temporarily suspends grants to HIV/AIDS strategy, pointing to greater-than-ever need Fund and World Bank. Uganda and terminates grants to Myanmar. for donors and developing countries to mobilize (July) As recommended by the Global Task Team, the around common national strategies to better fight the Global Joint Problem-Solving and Implementation (September) 11th Board of Directors meeting. disease. Cumulative Bank lending to fight HIV/AIDS Support Team is established with secretariat in Independent Panel of experts formed to review reported to exceed $2.5 billion. UNAIDS as a forum for international and multilateral disputed “No Go� decisions of Global Fund where phase 2 grants are suspended or stopped. (Global (December) Bank study, Reaching the Poor: What partners to mobilize and harmonize effective support Fund Annual Report) Works, What Doesn’t, and Why, warns of gaps to address challenges to effective use of increasing between intentions and verifiable results and reports external support and accelerated implementation of (September) International donors pledge $3.7 billion that health programs designed to reach poor people national AIDS responses; U.N. agencies, WHO, to Global Fund for two-year period, 2006 and 2007, at often end up helping the better off instead. Report World Bank, and Global Fund participate. replenishment conference chaired by U.N. Secretary- offers governments key policy steps to make sure that (July) G8 Summit agrees to double aid for Africa by General. disadvantaged people get crucial health services. 2010. Aid for all developing countries will increase, Global Fund, for the first time, includes in Round 5 according to the OECD, by around $50bn per year by financing for HSS to support HIV/AIDS, tuberculosis, 2010, of which at least $25bn extra per year will be for and malaria; 10 percent of such proposals accepted. Africa. A group of G8 and other countries will also (Global Fund Annual Report) First Global Fund grant take forward innovative financing mechanisms, for HSS approved for Rwanda and Cambodia. including the International Finance Facility for Global Fund largest funder of tuberculosis and immunization, and an air-ticket solidarity levy. G8 malaria control programs, and one of three largest for agrees that World Bank should have a leading role in HIV/AIDS, along with U.S. government and World supporting the partnership between the G8, other Bank; Global Fund accounts for two-thirds of donors, and Africa, helping to ensure that additional international spending on both tuberculosis and assistance is effectively coordinated. G8 and African malaria control. In 2005, total Global Fund leaders agree to provide as close as possible to disbursements $1.9 billion. (Global Fund Annual universal access to HIV/AIDS treatment by 2010. Report, 2006) Global Fund portfolio valued at nearly (Chair’s summary) $5 billion in 131 countries. (Global Fund Annual (September) Summit of World Leaders at U.N. Report) General Assembly “encouraged� that OECD (December) With Global Fund support, 384,000 estimates official development assistance will people receiving ARVs, 1,000,000 people under increase to $50 billion per year by 2010. Leaders Directly Observed Treatment Short-Course (DOTS), recommit to implementing goals of the U.N. Special and 7.7 million insecticide-treated bed nets (ITNs) Session of the General Assembly, including distributed. (Global Fund Annual Report) substantial funding of Global Fund and HIV/AIDS (December) First Global Fund Inspector-General programs of U.N. agencies and working to implement Appendix B 14 Date Global Fund World Bank Other takes office. (Global Fund Annual Report) the recommendations of the Global Task Team and (December) 12th Board of Directors meeting, “Three Ones� principles. Outcome document also Marrakech, Morocco. welcomes, with less detail, scaling up of bilateral and multilateral efforts on malaria and tuberculosis. (December) TERG releases study on CCM effectiveness. (November) Global Strategic Plan to combat malaria, 2005–2015, launched by RBM at Global Malaria Partners Forum in Yaoundé. 2006 (January) Product RED Initiative launched at World (January) Launching of ASAP program to help (January) “Global Fund – World Bank HV/AIDS Economic Forum in Davos. Sale of RED-branded countries in designing AIDS Strategy and Action Programs Comparative Advantage Study� by products benefits Global Fund AIDS programs. Plans, in partnership with UNAIDS. Alexander Shakow issued in response to 2005 Global (Global Fund Annual Report) (May) Bank report, Health Financing Revisited—A Task Team recommendation. (March) 13th Board of Directors meeting, Geneva, Practitioner's Guide, raises concerns about global (January) Launch of new Global Plan to Stop TB at decides to launch Round 6. (Global Fund Annual efforts to expand health care systems, says 2006 World Economic Forum, where Global Fund, Report) international aid must be increased and made U.S. government, WHO, and UNAIDS announce (April) Friends of the Global Fund, Europe, launched. predictable and sustainable. Report notes that results of their joint efforts to extend ARV treatment (Global Fund Annual Report) development assistance for health has increased and for HIV. suggests donors need to make a more concerted (March) Development Assistant Committee Friends of the Global Fund, Africa, launched. (Global effort to work with national governments to develop (DAC)/OECD meeting with 91 countries adopts Paris Fund Annual Report, nd) action plans and provide long-term, consistent Declaration on Aid Harmonization. (June) Global Fund launches Principal Recipient financing. Profusion of donor efforts is found to have campaign in Europe with pro bono support. (Global (May) African Union Summit on Universal Access to distorted country spending priorities, increased Fund Annual Report) HIV/AIDS, TB, and Malaria Treatment by 2010. transaction costs, and fragmented health service (July) G8 Summit held in St. Petersburg agrees on delivery. (July) G8 reaffirms commitments to fight HIV/AIDS, goal of universal access to HIV treatment by 2010. tuberculosis, and malaria and agrees to work further In its Annual Report, the Bank reports malaria Russian Federation moves from recipient to donor with other donors to mobilize resources for Global commitments of $167 million in FY06, and total status in Global Fund by committing $217 million Fund and to continue to pursue efforts to achieve as tuberculosis commitments of about $600 million in through 2010 to reimburse costs of all Global Fund closely as possible universal access to HIV/AIDS more than 30 countries. Total health and social projects in the country to date. (Global Fund Annual treatment by 2010. G8 also resolves to support the services commitments in the year: $2.2 billion. Report) Global Plan to Stop TB, aimed at saving up to 14 (July) As recommended by Global Task Team in million lives by 2015, and to provide resources in (July) Second biennial Partnership Forum, in Durban 2005, AIDS Strategy and Action Plan service cooperation with African countries to scale up action South Africa, with 414 participants from 118 countries, established by UNAIDS with coordinating unit located against malaria. (Chair’s summary) provides CSO input on Global Fund processes. E- in World Bank GHAP to provide technical support to Forum is held to expand online discussions (Sept) United to Aid (UNITAID) international drug countries on HIV/AIDS strategy and action planning. preparatory to Partnership Forum. purchase facility financed by air ticket levy in Bank issues Disease Control Priorities in Developing participating countries is launched to expand long- Mid-term review of Global Fund replenishment held. Countries, 2nd Edition (DCP2), covering health term access to low-priced quality drugs for the three (Global Fund Annual Report) conditions, diseases, and services, along with diseases. (Annual Report) (July) Non-U.S. contributions reach amount required synthesis volume Priorities in Health. 15 Appendix B Date Global Fund World Bank Other to permit full U.S. government $414 matching contribution. (August) Global Fund grants to Myanmar terminated for management weaknesses. Global Fund grants to Uganda suspended pending definition of new management modalities with Ministry of Finance; suspension lifted in November following MOU signature with Ministry of Finance. (August) Bill and Melinda Gates laud Global Fund at International AIDS conference in Toronto. Gates Foundation pledges an additional $500 million to Global Fund (August) Global Fund launches “Hope Spreads Faster than AIDS" global communications campaign to engage citizens, corporations, and civil society in taking action against AIDS. Global Fund Round 5 is the first Round to include financing HSS to support HIV/AIDS, tuberculosis, and malaria; 10 percent of such proposals accepted. (Global Fund Annual Report) (September) Board of Directors unable to approve all grants approved by the Technical Review Panel because of a shortfall of funds pledged for 2005 at the time. Board adds donor seat. (Global Fund Annual Report) (September) Two-year Global Fund replenishment of $3.7 billion agreed by Global Fund donors. (October) Product RED launched in United States with New York City press conference and Oprah Winfrey TV show appearance. Total public sector donor pledges in 2006: $2.2 billion (Global Fund Annual Report) (November) 14th Board of Directors meeting, Guatemala; elements of Global Fund four-year strategic framework adopted. Board of Directors fails to reach consensus of two-thirds majority within each voting group on new executive director and decides to Appendix B 16 Date Global Fund World Bank Other continue the search process. (Global Fund Annual Report and press release) (November) Two grants to Chad suspended for Global Fund resource misuse. (Global Fund Annual Report) Board of Directors decides to discontinue Global Fund administrative services agreement with WHO. (Annual Report, nd) (December) As of end-December, 384,000 people have begun ARV treatment with Global Fund support, 7.7 million ITNs against malaria distributed, and tuberculosis programs detected and treated more than 1 million cases. $1.9 billion disbursed. Sixty-four percent of funding to low-income countries and 57 percent to Sub-Saharan Africa. (Global Fund Annual Report) At end-2006, Global Fund had approved $6.9 billion in grants for 450 projects in 136 countries, total cumulative disbursements: $3.2 billion. (Global Fund Annual Report) 2007 (March) As of March 2007, Global Fund had raised With health systems performance a dominant theme, (April) RBM announces campaign to improve quality $10 billion, 450 projects approved in 136 countries. Bank Annual Report highlights $1.83 billion in new of proposals from African countries to Global Fund. (Global Fund Annual Report) HNP commitments in FY07, including $300 million for Newly formed RBM Harmonization Working Group (April) Director of French National Agency for AIDS HIV/AIDS. co-chaired by UNICEF and World Bank to lead Research Michel Kazatchkine takes office as second (June) Bank releases Africa Region study of Bank’s campaign, to focus exclusively on supporting and Global Fund Executive Director, initiates two-year Africa MAP program to fight HIV/AIDS, which accelerating malaria control implementation at the Secretariat restructuring for a rapidly growing provided $1.3 billion for HIV/AIDS in Africa over six country level. organization. years. Country results achieved with MAP support (June ) OECD High-Level Meeting on Medicines for (April) Global Fund Board of Directors and G8 included infection prevention, activities to mitigate Neglected and Emerging Diseases in the Netherlands endorse Global Fund annual resource target of up to AIDS impact, and treatment of opportunistic focuses on tuberculosis and malaria. $8 billion. Board of Directors elects Rajat Gupta, infections. (June) G8 summit reaffirms commitment to fighting former managing director of McKinsey & Company, (August) Bank releases Policy Working Paper that HIV/AIDS, tuberculosis, and malaria and HSS by as chair. FYE formally launched. finds tuberculosis the most important infectious cause providing at least $60 billion “over the coming years.� (April) Rolling Continuation Channel introduced — of adult deaths after HIV/AIDS in low- and middle- G8 agrees that “the Global Fund continues to enjoy strongly performing grants receive continued funding income countries and evaluates economic benefits of our full support,� and to “provide predictable, long- for additional six years. Grant consolidation on a WHO DOTS Strategy in Global Plan to Stop TB, term additional funding� under the replenishment then 2006–15. Analysis finds that economic benefits of 17 Appendix B Date Global Fund World Bank Other country basis begins piloting. sustaining DOTS at current levels relative to having being negotiated. (Chair’s summary) (April) Board of Directors decides to increase target no DOTS coverage significantly greater than costs in (July) Informal inaugural meeting of the Health-8 (or for Global Fund grant approvals from $6 billion to $8 22 high-burden, tuberculosis-endemic countries and H8, as it has become known) — WHO, World Bank, billion per year by 2010. (Global Fund Annual Report) Africa. GAVI, Global Fund, UNICEF, United Nations (September) Second Voluntary Replenishment (September) Updated Bank HNP strategy focuses on Population Fund (UNFPA), Bill and Melinda Gates Conference in Berlin has pledges of $6.3 billion; total HSS and calls for redoubling efforts to improve Foundation, UNAIDS — aimed at strengthening expected resources are $10 billion for 2008–10, results, protect households from illness, and improve cooperation on global health; WHO and World Bank tripling Global Fund resources. (Global Fund Annual sector governance. Strategy observes significant provide secretariat. Report) increase in complexity of HNP assistance architecture (September) Launching of International Health and relatively reduced financial role of Bank. Partnership (IHP+), bringing together developing (September) Global Fund initiates new “Debt2Health� financing mechanism, supported by Germany, IFC-World Bank study of Business of Health in Africa countries (15 African and Asian countries in 2007), Indonesia, UNAIDS, Gates Foundation, the Global finds that private sector delivers about half of Africa’s international agencies, and donors (10 bilateral AIDS Alliance, Erlassjahr.de, and the Make Poverty health products and services and calls for close donors in 2007) in support of mutual accountability for History Campaign in Australia. Donor country forgoes partnership between public and private sectors. the health MDGs. repayment of debt, which is converted into health (September) Bank joins International Health (September) At Clinton Global Initiative meeting, sector investments by recipient country through Partnership. Norwegian Prime Minister leads launch of a global Global Fund grant process. Germany commits Euro (November) Norway announces $105 million Health campaign to save women’s and children’s lives, and 200 million to Debt2Health. Indonesian debt of Euro Results Innovation Grant for Bank to pilot results- pledges $1 billion in results-based financial support. 50 million canceled and Indonesia releases Euro 25 based financing to link funding to verifiable better UNITAID financing of tuberculosis and malaria million to Global Fund. (Global Fund Annual Report) health care for mothers and their infants, in keeping treatments $145 million in 2007. (Global Fund Annual (October) FYE Study Area 1 study issued, with MDGs. Report) Organizational Effectiveness and Efficiency of the (December) Negotiations completed on 15th IDA Global Fund. Replenishment, with pledges of $41.7 billion, Technical assistance support (cash and kind) from including debt relief and new financing by 45 donor other development agencies increases. U.S. gave countries of $25.2 billion. (FY08 Annual Report) $31 million support for technical assistance. “Idol Gives Back� charity campaign of U.S. TV show generates $6 million for Global Fund in 2007. (Global Fund Annual Report) With 76 Round 7 grants approved, Global Fund portfolio reaches $10.1 billion, with 550 grants in 136 countries; 20 percent of Round 7 funding is devoted to HSS. (Global Fund Annual Report) Appendix B 18 Date Global Fund World Bank Other 2008 (January) Inspector-General John Parsons joins (January) Bank announces that Indian (February) U.N. Secretary-General appoints Global Fund. (Global Fund Annual Report) government and Bank are joining forces to fight Special Envoy on Malaria. ( January) Corporate Champions Program launched. fraud and corruption and systemic deficiencies (February) U.S. President Bush announces a five- Chevron invests $30 million over three years in Global in India’s health sector, with immediate steps to year, $350 million initiative to combat neglected Fund programs in Asia and Africa. Product RED investigate indicators of wrongdoing and tropical diseases (TDs) in high-priority countries raises $39 million at Valentine’s Day auction of artists’ implement further safeguards. Government across Africa, Asia, and Latin America. donations. (Global Fund Annual Report) announces intention to reexamine ongoing and (July) In Japan the G8 leaders renew the future projects to ensure that they incorporate Dual-Track Financing introduced, under which Global commitments they undertook in 2005 to lessons from a Detailed Implementation Fund endorses inclusion of both government and increase development assistance to Africa by Review carried out by Bank’s Department of NGOs to act as Principal Recipients under each $25 billion yearly by 2010 with respect to the Institutional Integrity and publicly released. The proposal. (2010 Progress Report) 2004 level. A shorter timescale established for Review found serious incidents of fraud and Global Fund endorses strengthening of community- implementation of the commitment undertaken corruption in five health projects. based organizations (CBOs) to achieve sustainable in 2007 to provide $60 billion to support In FY08 International Bank for Reconstruction and measures to combat infectious diseases and delivery systems. Development (IBRD)/IDA committed $948 million to improve health care. G8 leaders also renew Global Fund Board of Directors approves pilot for new HNP operations. Thanks to a trust fund financed by their commitment to ensure universal access to Affordable Medicines Facility for Malaria (AMFm) to Norway, the Bank pledged $100 million for results- HIV/AIDS prevention measures by 2010. In support ACT treatment.(Global Fund Annual Report, based HNP financing in at least four countries. (World malaria prevention, the G8 leaders agree to nd) Bank Annual Report) provide 100 million mosquito nets by 2010. (March) Starting with Round 8 grants, Global Fund (May) Bank releases its updated African AIDS (August) At International AIDS conference in encourages applicants to include HSS in disease strategy, The World Bank’s Commitment to HIV/AIDS Mexico, former Botswana President Festus control proposals. (Global Fund Annual Report) With in Africa: Our Agenda for Action, 2007–2011. Strategy Mogae launches “Champions for an HIV-free Round 8, total portfolio value reaches $15 billion in states that for every infected African starting ART for Generation,� a group of renowned African 140 countries. (Global Fund Annual Report) the first time, another four to six become newly leaders calling for their peers to rethink and (June) FYE Study Area 2 study issued, The Global infected. step up efforts to prevent the spread of HIV, Fund Partner Environment, at Global and Country Annual Report mentions commitment, from FY05 including former Presidents of Mozambique, Levels, in Relation to Grant Performance and Health through FY08, of about $470 million in IDA and trust Tanzania, and Zambia, Archbishop Desmond System Effects, including 16 Country Studies. fund resources for malaria control in Africa through Tutu, an Ethiopian super model, and a South Global Fund and UNITAID join forces (Joint Roadmap the booster program — more than nine times the African Supreme Court of Appeal Justice. announced) to improve procurement, pricing and volume of resources committed for this between 2000 (September) Accra Agenda for Action (AAA) adopted availability of medicines and diagnostics. and 2005. Total FY08 commitments for health and by donors and development partners, in follow-up to Second Global Fund Debt2 Health Initiative. other social services: $1.6 billion. [annual report] the Paris Declaration, extends beyond aid (November) Global Fund Board of Directors approves (December) Bank launches Phase II of its Malaria harmonization at the country level to focus on Round 8 grant financing of $2.75 billion. (Global Fund Booster program. strengthening country ownership and creative Annual Report) inclusive partnerships, underscoring mutual accountability for results and identifying concrete (December) Administrative services agreement with actions for all development partners. ( FY09 Annual WHOI terminated. Report) 19 Appendix B Date Global Fund World Bank Other (December) First Lady of France Carla Bruni-Sarkozy (September 25) World leaders and the global malaria becomes Global Fund Ambassador for protection of community gather on occasion of the 2008 U.N. MDG mothers and children against AIDS, visits clinics in Summit on September 25, 2008, in New York to Burkina Faso. (Global Fund Annual Report) endorse a Global Malaria Action Plan facilitated by (December) Third Partnership Forum, Dakar, RBM; substantial new resources mobilized, and generates 28 recommendations to Board of Directors partners agree on target to eliminate malaria in 8–10 and Secretariat. (2010 progress report) countries by 2015. (Global Fund Annual Report/ RBM 2nd evaluation). Round 8 funding: $2.75 billion for malaria (RBM second evaluation) (October) CoATS (Coordinating AIDS Technical Support) database launched by UNAIDS to assist lLFAs: Global Fund Global Fund Annual Report lists countries to monitor technical support and facilitate 12 organizations serving in this capacity, including greater accountability and country ownership of World Bank and UN OPS. HIV/AIDS technical assistance. 2008 Global Fund disbursements: $2.3 billion. Of total Thanks to PEPFAR and Global Fund investments, 3.5 Global Fund investments, 68 percent are in low- million people reported on ARVs. (Global Fund income countries and 25 percent in lower-middle- Annual Report) income countries, 60 percent in Sub-Saharan Africa, 35 percent, or about $4 billion, supporting HSS components. Global Fund providing 23 percent of international financing for HIV/AIDS, 60 percent for malaria, and 57 percent for tuberculosis. Contributions and pledges in 2008: $3.1 billion, $12.8 billion; total approved grants, $14.8 since inception. Private sector: 6.6 percent of total Global Fund contribution. (Global Fund Global Fund Annual Report) Product RED brings $68 million to Global Fund in 2008. (Global Fund Annual Report) Total staff at end 2008: 392. (Global Fund 2009 Annual Report) 2009 Thirty-two percent of Global Fund resources to (March) Progress report to Board on implementation (February) IHP+ organizes health summit in Geneva. programs implemented by CSOs, 56 percent of 2007 HNP strategy underscores HSS and (May) High-level Taskforce on Innovative International implemented by government agencies, and 6 percent importance of strengthening the HNP portfolio, cites Financing for Health Systems, co-chaired by U.K. implemented by UNDP. (Global Fund Annual Report.) examples of results-based financing, underscores prime minister and World Bank president, releases Global Fund Annual Report lists programs and multisectoriality of HNP support, mentions that about report recommending inter alia establishing a health funding by country rather than individual grant. one-half of Poverty Reduction Support Credit systems funding platform for the Global Fund, GAVI AMFm hosted by Global Fund launched with eight operations have an HNP aspect, and stresses IHP+ Alliance, the World Bank, and others to coordinate, Appendix B 20 Date Global Fund World Bank Other pilots, in follow-up on U.S. Institute of Medicine 2004 cooperation. mobilize, streamline, and channel the flow of existing study. (April) IEG releases evaluation of $17 billion in World and new international resources to support national (February) Global Fund and Stop TB Partnership sign Bank support for HNP since 1997, two-thirds with health strategies. MOU. Core areas for cooperation include support to satisfactory outcomes, but portfolio performance (May) Under general umbrella of IHP+, launch of Joint Global Fund grantees by the Global Drug Facility and stalling. IEG finds the Bank financing a smaller share Funding Platform for HSS (Global Fund, GAVI, and Green Light Committee; coordination of technical of HNP support and observes that excessive World Bank, facilitated by WHO, with secretariat in assistance; and M&E. earmarking of foreign aid for communicable diseases World Bank). Platform based on four principles: (a) (February) Pacific Friends of Global Fund joins (their reduction being an objective of 35 percent of one national health strategy; (b) one joint assessment Friends organizations in Africa, U.S., Japan, Europe, HNP operations) can distort allocations and reduce of national health strategy by development partners Latin America, and South and West Asia as NGO health system capacity. It recommended that the using the Joint Assessment of National Strategies advocates for Global Fund. Bank carefully assess decisions to finance additional (JANS) tool; (c) one fiduciary framework, including freestanding communicable disease programs in financial management and procurement; and (d) one (March) FYE synthesis report issued, The Five Year countries where other donors are contributing large M&E framework based on country systems. Platform Evaluation of the Global Fund to Fight AIDS, TB, and amounts of earmarked disease funding. work program focuses on new funding informed by Malaria: Synthesis of Study Areas 1, 2, and 3, with (April) Bank report, Averting a Human Crisis during the JANS, harmonization and alignment of existing Board of Directors discussion. the Global Downturn: Policy Options from the World support at the country level, and harmonization of (May) Global Fund plans Code of Conduct for GAVI and Global Fund HSS proposal forms. Bank's Human Development Network, presents providers of goods and services financed with Global findings from a March 2009 survey conducted in 69 (July) G8 recognizes contributions of Global Fund, Fund resources. countries, which offer treatment to 3.4 million people WHO, and World Bank to health in developing (May) FYE Study Area 3 study issued, The Impact of on ART, suggests that 8 countries face shortages of countries and encourages them to cooperate with Collective Efforts on the Reduction of the Disease antiretroviral drugs or other disruptions to AIDS developing countries on country-led strategies and Burden of AIDS, Tuberculosis, and Malaria. treatment. Twenty-two countries in Africa, the plans. G8 reaffirms existing commitments, including (May) Gender Equality Strategy and the Strategy on Caribbean, Europe and Central Asia, and East Asia $60 billion to fight infectious diseases and strengthen Sexual Orientation and Gender Identities adopted. and the Pacific expect to face disruptions. These health systems by 2012. G8 encourages multilateral (June) Voluntary pooled procurement approved, for countries are home to more than 60 percent of people institutions — including WHO, World Bank, GAVI, collective purchase of drugs by countries, amounting worldwide on AIDS treatment. HIV/AIDS prevention UNITAID, Global Fund, and U.N. agencies — to to 30 countries, 98 orders, total order value $27 programs are also in jeopardy. Thirty-four countries continue to support HSS. (communiqué) million by the end of 2009. (Global Fund Global Fund representing 75 percent of people living with HIV In cooperation with RBM and other partners, United Annual Report) already see an impact on prevention programs that Against Malaria Campaign launched by private firms HSS: Round 9 funding $738 million, total funding target their high-risk groups. in South Africa to mobilize awareness and financial committed and signed by end-2009: $1.2 billion. FY09 HNP lending reaches $2.9 billion — a threefold resources for Global Fund, stimulated by South (Global Fund Annual Report) increase over previous year. Disbursements and new Africa’s hosting of World Cup soccer. (Global Fund (July) Minister of Health of Ethiopia elected Global commitments for HIV/AIDS were $290 million and Annual Report) Fund Board of Directors chair. $326 million. (World Bank Annual Report) Analytical (September) Launch of African Leaders Malaria work on HIV/IDS in FY09 includes a 71-country Alliance on occasion of 64th U.N. General Assembly. (August) As a result of unaccounted funds, Global survey of the impact of economic crisis on efforts to Fund stops disbursing funds to Ministry of Health in (G8 communiqué) prevent disruptions in treatment and prevention Zambia, transfers resources to UNDP. (September) Second evaluation of RBM released, programs. (World Bank Annual Report) covering 2004–08, finding renaissance of 21 Appendix B Date Global Fund World Bank Other (September) Inspector-General makes Annual Report reports MAP providing $1.8 billion to engagement on malaria since the founding of RBM in recommendations to strengthen grant processes. Africa since 2001 for prevention and treatment in 1998. Confirmed malaria funding grew from $200 (Progress Report) more than 30 countries. To combat malaria, Bank million in 2004 to $688 million in 2006, and 2004–08 (November) 20th Board of Directors meeting approves committed more than $1 billion for Phase II (2009–12) period was a time of success in the fight against new grant architecture, providing for National of the Malaria Booster Program in Africa. malaria and for RBM and its partners. Successes Strategy Applications, to be piloted with $434 million include seven African countries/areas reporting 50 in grants. (Global Fund Annual Report) percent reduction in malaria cases between 2000 and 2006. Agreed malaria goals now include universal (November) Board of Directors approves coverage by 2010 and zero deaths by 2015. Debt2Health as permanent feature of Global Fund resource mobilization. (Global Fund Annual Report) (September) Gates Foundation report issued, GAVI and Global Fund Joint Programming for Health By end-2009, Global Fund-supported programs Strengthening: Turf Wars or an Opportunity to do saving 3,600 lives a day, AIDS treatment to 2.5 million Better. people, detection and treatment of a total of 6 million new active tuberculosis cases, a cumulative total of 104 million ITNs, total 4.9 lives saved by end 2009. (Global Fund Annual Report, 2010 Progress Report) Grant portfolio at end-2009, by disease: HIV/AIDS, 55 percent; ; tuberculosis, 16 percent; malaria, 29 percent; 57 percent, Sub-Saharan Africa; planned grant expenditure: 24 percent, human resources and training; 21 percent, medicines; 18 percent, health equipment and products; 12 percent, program management; 4 percent, M&E. (Global Fund Annual Report) Total pledges in 2009: $3.3 billion, private sector contributions; $43 million (Global Fund Annual Report); total approved proposals, $19.2 billion; total disbursements, $10 billion; portfolio, 144 countries; $5.9 billion in commitments in fragile states, 41 percent of total in fragile states. Total funds raised by end-2009: $21 billion. (Global Fund 2010 Progress Report) Nearly $1billion freed up for funding new grants by reallocation from poorly performing grants. (Global Fund 2010 Progress Report) 2009 policy adjustments to improve aid effectiveness at the country level: coordination of country program Appendix B 22 Date Global Fund World Bank Other salaries with local or agreed international framework, support for alignment with adequate country systems and cycles for procurement, financial management, and M&E, Global Fund local financial transparency and accountability with guidelines for Global Fund aid reporting. (Global Fund 2010 Progress Report) As of end-2009, Product RED has raised $140 million to support programs in four African countries. (Global Fund 2010 Progress Report) From 2005 to 2009 nearly 80 percent of grants assessed as performing well, tuberculosis best- performing grants, and CSOs best performing Principal Recipients. (Global Fund 2010 Progress Report) Total employees at end 2009: 569. (Global Fund Annual Report) Five Year Evaluation: (March ) Final report issued (May) Board and Policy and Strategy Committee discuss FYE. 2010 Global Fund adopts new grant architecture, with (May) Bank releases five-year reproductive health (June) G8 Summit in Canada reaffirms commitment to single stream of funding per Principal Recipient per action plan to help poor countries reduce high fertility “come as close as possible to universal access to disease. rates and prevent deaths of mothers and children. prevention, treatment, care, and support with respect Global Fund publishes “Global Fund Aid Effectiveness Bank warns that family planning and other to HIV/AIDS.� G8 agrees to “support country-led Scorecard� with data from 2005, 2007, and 2008, with reproductive health programs have fallen off efforts to achieve this objective by making the third 2010 targets, according to Paris Declaration and DAC development radars of many low-income countries, voluntary replenishment conference of the Global criteria (Global Fund 2010 Progress Report) donor governments, and aid agencies. Fund to Fight AIDS, TB and Malaria in October 2010 (June) Bank study of results-based financing for a success.� G8 encourages “other national and Global Fund lists changes in policies and processes health presented, on definitions and concept, private sector donors to provide financial support for made in response to recommendations of Technical measurement, and global experience. the Global Fund.� G8 launches the “Muskoka Review Panels. (Global Fund 2010 Progress Report) Initiative, a comprehensive and integrated approach Global Fund Inspector-General reports misuse of FY10 HNP commitments of $4.2 billion exceed to accelerate progress towards MDGs 4 and 5 that funds in 4 of 145 countries with Global Fund financial previous year. Eleven new projects commit $194 will significantly reduce the number of maternal, support. (Global Fund press release, early 2011) million for HIV/AIDS. Overall HNP portfolio of $10 newborn and under five child deaths in developing billion, of which more than half in the poorest FYE key recommendations and Global Fund countries.� countries. To strengthen AIDS operations, AIDS Secretariat response tabulated in Global Fund (July) 13th International AIDS conference Strategy and Action Plan (ASAP) services reach 65 23 Appendix B Date Global Fund World Bank Other Progress Report. countries, and GAMET provides M&E support to 25 (August) Nepal’s leading health aid donors― DFID, (April) Global Fund and RBM sign MOU under which countries. Bank works with partners to build a Health World Bank, GAVI, USAID, UNFPA, and UNICEF ― they commit to work together to keep malaria a global Systems Funding Platform to support country agree to funnel financial support through one health priority, to generate high-quality proposals from progress towards national health goals and the simplified aid management system, in early as many affected countries as possible, and to MDGs. (Annual Report) application of Health Systems Funding Platform. monitor the implementation and impact of overall (September) Bank releases study of Unfinished Arrangement brings together donors able to pool their response to malaria. Business: Mobilizing New Efforts to Achieve the 2015 support (World Bank, DFID, and GAVI) and others Millennium Development Goals for U.N. MDG review such as USAID, UNFPA, and UNICEF that provide (May) Global Fund launches Round 10 of grant summit outlining developing countries’ progress in on-budget resources but do not pool their funds. proposals. overcoming poverty until recent food, fuel, and (October) MDG Review Summit at U.N. General (September) Board of Directors decides to introduce financial crises. Report estimates that as a result of Assembly “recognizes� that more attention should be multi-year contribution agreements with public donors these crises, 64 million more people are living in paid to Africa. While aid to Africa has increased, it has and promissory notes with private donors. (Chair extreme poverty in 2010, and some 40 million more fallen behind commitments. Leaders commit replenishment summary) people went hungry in 2009. By 2015, 1.2 million themselves to redoubling efforts strengthen national (October) Global Fund hosts side event with public more children under five might die, and about 100 health systems and to combat HIV/AIDS. Under MDG policy and celebrity Champions of Global Health at million more people might remain without access to 4, on child health, leaders commit to maintaining U.N. MDG review summit. safe water. progress on malaria, including extending use of ITNs. October) Global Fund-sponsored Born HIV Free (December) IDA 16 replenishment for $49.3 billion, On MDG 6, on combating HIV/AIDS, malaria, and campaign reaches symbolic completion with U.N. over three years, agreed, including 51 donors and other diseases, leaders commit to redoubling e Secretary-General receiving a book containing some stress on improving health services and 4 special treatment, care and support. Efforts against of the 700,000 names of people who signed up in themes: crisis response, gender, climate change and HIV/AIDS, tuberculosis, malaria, and other diseases support of the Global Fund. Names—gathered from fragile and conflict-affected countries (World Bank to include adequate funding of Global Fund and other the campaign Web site, YouTube, and through press release, IDA deputies report) bilateral and multilateral programs efforts for universal advocacy partners—form part of a call for sufficient access to HIV/AIDS prevention. funds to be made available to achieve elimination of mother-to-child transmission of HIV by 2015. Campaign reached 20 million respondents and 250 million viewers. (October) Global Fund Third Voluntary Replenishment for 2011–13 chaired by U.N. Secretary-General Ban includes pledges and projections of $11.7 billion, with 50 participating delegations; additional $2.5 billion expected by Secretariat beyond the pledged $11.7 billion. Pledges represent 20 percent increase. (Global Fund Web site), but replenishment falls short of investing the $20 billion estimated to be needed to fully fund the fight against the three pandemics. A day after the replenishment meeting, several newspapers, in the U.K., Spain, France, and Germany, showed Appendix B 24 Date Global Fund World Bank Other support for the Global Fund by donating one-page advertisements to allow Global Fund to thank the general public and government donors for their support. (December) Dow Jones Indexes launches a new index, in collaboration with Global Fund. The Dow Jones Global Fund 50 Index measures performance of the largest companies that support the Global Fund mission. A portion of revenues generated through licensing the index will go to the Global Fund. Global Fund disburses $3 billion in 2010. Secretariat creates 49 single-stream funding arrangements and reduces total number of grants by 10 percent. 2011 (January) Germany and Sweden, joined separately by (June) June 2011 – Bank study resulting from (February) U.S. President Obama’s budget proposals Spain and Denmark, suspend total of $180 million in partnership with UNDP and Johns Hopkins School of for FY12 foresee exemption of foreign assistance Global Fund contributions pending outcome of review Public Health provides evidence that better HIV from freeze in discretionary spending, small increases of allegations of misuse of funds. (press reports) prevention, care, and treatment services for men who in funding for HIV/AIDS, tuberculosis, and malaria. (March) Global Fund announces establishment of have sex with men; improve overall HIV epidemic (Center for Global Development Web site). independent panel reporting to Board of Directors, co- control (March) Despite overall approach of budget cuts, aid chaired by former President of Botswana and a (June) World Bank IFC affiliate issues assessment of review by new U.K. government reaffirms promise to former Republican U.S. Secretary of Health and how governments and private health sector work reach U.N.’s 0.7 percent of GNP aid target by 2013. Human Services, to review financial safeguards, together in 45 African countries. Global Fund and IDA among 9 of 43 multilateral controls, and anti-corruption protections; initial organizations assessed in top category as providing very measures to strengthen financial safeguards good value for U.K. aid money, UNITAID assessed as announced. Global Fund grant to Mali suspended for providing good value, WHO and UNAIDS providing misuse of funds. (Global Fund press releases) adequate value. Global Fund found to be largest (May) 23rd Board of Directors meeting. Board multilateral funder of health MDGs, with weaknesses in endorses five-year strategy, including a �market- its business model because Global Fund systems often shaping� program aiming to optimize price, quality, take precedence, despite country-led approach; Global design, and sustainable supplies of health products, Fund insufficiently flexible in fragile states. IDA’s internal initially ARVs. Board of Directors elects former DFID incentives found to focus on inputs rather than results; director-general as chair. review critical of IDA’s high transaction costs and limited use of country systems. Review finds Global Fund critical (June) Global Fund, Germany, and Egypt sign new to achievement of health MDGs but concludes that type of Debt2Health agreement under which Germany Global Fund is burdensome for countries and partners. agrees to write off €6.6 million of Egyptian debt, while Review finds IDA comparative advantage is breadth and Egypt agrees to contribute half of this amount to quality of technical knowledge, expertise, and global Global Fund programs to fight malaria in Ethiopia. 25 Appendix B Date Global Fund World Bank Other reach. Review cites partnership behavior as area for reform under IDA 16. (April) Republican alternative to U.S. President Obama’s FY12 budget proposals would cut international affairs spending by 40 percent. Final FY11 budget agreed by executive and legislative branches with substantial cuts in domestic and international affairs spending. However, IDA approved at $1.235 billion, without a cut, PEPFAR approved at $4.6 billion, without a cut, and Global Fund approved at $1.05 billion, without a cut. ( ONE campaign Web site) (June) U.N. Security Council meets on HIV/AIDS for second time, after initial meeting in 2000; UNAIDS executive director underscores need for a new response to AIDS in U.N. actions to help prevent conflict, ensure security and build peace. U.N. General Assembly holds 2nd High-Level meeting on HIV/AIDS, after 2001 UNGASS session, with 30 presidents, vice presidents and heads of government. U.N. Secretary- General articulates common goal of an end to AIDS within the decade—zero new infections, zero stigma, and zero AIDS-related deaths. General Assembly declaration mentions eightfold increase in funding to combat AIDS from 2001 to $16 billion in 201, but states that funding did not increase in 2010 and that the more than $30 billion donor commitments to Global Fund has fallen short of Global Fund targets. (June) U.N. Secretary-General and U.S. government launch initiative Countdown to Zero to eliminate HIV among babies by 2015, at estimated cost of $2.5 billion; plan developed by UNAIDS and PEPFAR, and supported by Global Fund. Sources: World Bank Annual Reports at http://search.worldbank.org/all?qterm=annual%20reports; Global Fund Annual Reports at http://www.theglobalfund.org/en/library/publications/annualreports/; Global Fund press and media releases at http://www.theglobalfund.org/en/mediacenter/; World Bank press and media releases at http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,pagePK:34382~piPK:34439~theSitePK:4607,00.html 26 Appendix C Appendix C. Global Fund: Purpose, Principles, and Results Chain Source: “Framework Document of the Global Fund to Fight AIDS, Tuberculosis and Malaria� (Global Fund 2003). Purpose The purpose of the Fund is to attract, manage and disburse additional resources through a new public-private partnership that will make a sustainable and significant contribution to the reduction of infections, illness and death, thereby mitigating the impact caused by HIV/AIDS, tuberculosis and malaria in countries in need, and contributing to poverty reduction as part of the Millennium Development Goals. Principles A. The Fund is a financial instrument, not an implementing entity. B. The Fund will make available and leverage additional financial resources to combat HIV/AIDS, tuberculosis and malaria. C. The Fund will base its work on programs that reflect national ownership and respect country-led formulation and implementation processes. D. The Fund will seek to operate in a balanced manner in terms of different regions, diseases and interventions. E. The Fund will pursue an integrated and balanced approach covering prevention, treatment, and care and support in dealing with the three diseases. F. The Fund will evaluate proposals through independent review processes based on the most appropriate scientific and technical standards that take into account local realities and priorities. G. The Fund will seek to establish a simplified, rapid, innovative process with efficient and effective disbursement mechanisms, minimizing transaction costs and operating in a transparent and accountable manner based on clearly defined responsibilities. The Fund should make use of existing international mechanisms and health plans. H. In making its funding decisions, the Fund will support proposals which: 1. Focus on best practices by funding interventions that work and can be scaled up to reach people affected by HIV/AIDS, tuberculosis and malaria. 2. Strengthen and reflect high-level, sustained political involvement and commitment in making allocations of its resources. Appendix C 27 3. Support the substantial scaling up and increased coverage of proven and effective interventions, which strengthen systems for working: within the health sector; across government departments; and with communities. 4. Build on, complement, and coordinate with existing regional and national programs1 in support of national policies, priorities and partnerships, including Poverty Reduction Strategies and sectorwide approaches. 5. Focus on performance by linking resources to the achievement of clear, measurable and sustainable results. 6. Focus on the creation, development and expansion of government/private/NGO partnerships. 7. Strengthen the participation of communities and people, particularly those infected and directly affected by the three diseases, in the development of proposals. 8. Are consistent with international law and agreements, respect intellectual property rights, such as TRIPS, and encourage efforts to make quality drugs and products available at the lowest possible prices for those in need. 9. Give due priority to the most affected countries and communities, and to those countries most at risk. 10. Aim to eliminate stigmatization of and discrimination against those infected and affected by HIV/AIDS, especially for women, children and vulnerable groups. 1. Including governments, public/private partnerships, NGOs, and civil society initiatives. Appendix C 28 Table C-1. Global Fund: Results Chain Activities Financed Outputs Outcomes Impacts HIV/AIDS Support for screening and quality Expanded screening of and improved Safer blood products. Reduced transmission of HIV through assurance of blood products. blood transfusion services. contaminated blood products. Appropriately designed programs, Inclusive programs that reach men who High-risk groups have greater access to including support for programs addressing have sex with men, sex workers, injecting and seek services. high-risk groups in countries with drug users (needle exchanges, etc.). concentrated epidemics. Expanded sites for voluntary counseling Expanded capability for counseling and Pregnant women positive for HIV treated Reduced mother-to-child transmission of and testing. testing of pregnant women for HIV and with ART to prevent mother-to-child HIV and reduced infections in adolescents. counseling of adolescent in sex behavior. transmission of HIV; and more responsible sex behavior in adolescents. Appropriate market and research inputs for Well-designed, effective communications Desired behavior change in targeted information, education and communication and counseling programs promoting safe groups, e.g., people with more than one sex (IEC) and community mobilization sex (condom use) and other behavioral partner in past 12 months use condoms in programs. change, e.g., seeking testing and last sexual intercourse. counseling, targeted at high-risk groups. Support for ART through public and NGO Identification of populations affected with People living with AIDS treated with ART. Increased numbers of people living with networks. HIV and enrolment into treatment. AIDS continuing to receive ART treatment. programs. Tuberculosis Training and supplies for expanded and Improved case detection of tuberculosis Early and effective treatment of Decline in tuberculosis prevalence. improved tuberculosis detection, referral, and early treatment opportunities. tuberculosis. Higher cure rate. and treatment (include testing of HIV/ AIDS populations where appropriate). Support and supplies to expand DOTS. Improved access to tuberculosis DOTS Early and effective treatment of services and drugs. tuberculosis. Higher cure rate. Health systems strengthening. Tuberculosis interventions integrated into Efficiency gains – through system Decline in tuberculosis prevalence. 29 Appendix C Activities Financed Outputs Outcomes Impacts general health services. strengthening. Support for diagnosis of multiple-drug- More cases of multiple-drug-resistant Improved control of multiple-drug-resistant resistant tuberculosis and availability of tuberculosis identified and treated with tuberculosis. drugs to treat them. appropriate drugs. Malaria Support for pharmacovigilance in countries Regulatory authorities equipped with Regulatory authorities acting on their Reduced risk of drug resistance. with drug resistance. knowledge, skills, and equipment to fight knowledge and equipment. counterfeit drugs. Support for expanded distribution networks At risk population seeking bed nets and Increased number of people sleeping under Reduced malaria mortality. and access to impregnated bed nets; having greater access to them. Improved treated bed nets, especially children under social marketing. understanding of risks to children under five. five. Support for programs targeted to Intermittent prophylaxis of expectant Women positive for malaria treated with Reduced mother-to-child transmission of expectant mothers. mothers against malaria in high-burden appropriate antimalarials to prevent malaria. countries. transmission to newborn. Health Systems Strengthening Conduct of surveys (Sentinel Surveillance, Appropriately designed programs that are See above. See above. Demographic Health, and Behavioral) and country-specific and contextual; e.g., epidemiological and analytical studies to appropriate mix of prevention, treatment, strengthen evidence base for national and care and support strategies for all program response. three diseases as described below. Training and capacity building of institutions (public and private, NGO) to improve skills competency and quality of services (e.g., improved capability in tuberculosis detection and diagnosis, interventions to combat drug resistant strains of malaria). Source: Constructed by IEG. Appendix D 30 Appendix D. Global Fund: Core Structures Source: The Global Fund, www.theglobalfund.org/en/structures/?lang=en Country Coordinating Mechanism (CCM): At country level, this is a partnership composed of all key stakeholders in a country’s response to the three diseases. The CCM does not handle Global Fund financing itself, but is responsible for submitting proposals to the Global Fund, nominating the entities accountable for administering the funding, and overseeing grant implementation. The CCM should preferably be an already-existing body, but a country can instead decide to create a new entity to serve as CCM. Global Fund Secretariat: This manages the grant portfolio, including screening proposals submitted, issuing instructions to disburse money to grant recipients, and implementing PBF of grants. More generally, the Secretariat is tasked with executing Board policies; resource mobilization; providing strategic, policy, financial, legal, and administrative support; and overseeing M&E. It is based in Geneva and has no staff located outside its headquarters. Technical Review Panel: This is an independent group of international experts in the three diseases and cross-cutting issues such as health systems. It meets regularly to review proposals based on technical criteria and to provide funding recommendations to the Board. Global Fund Board: This is composed of representatives from donor and recipient governments, civil society, the private sector, private foundations, and communities living with and affected by the diseases. The Board is responsible for the organization’s governance, including establishing strategies and policies, making funding decisions, and setting budgets. The Board also works to advocate and mobilize resources for the organization. Principal Recipient: The Global Fund signs a legal grant agreement with a Principal Recipient, which is designated by the CCM. The Principal Recipient receives Global Fund financing directly, and then uses it to implement prevention, care, and treatment programs or passes it on to other organizations (sub-recipients) who provide those services. Many Principal Recipients both implement and make sub-grants. There can be multiple Principal Recipients in one country. The Principal Recipient also makes regular requests for additional disbursements from the Global Fund based on demonstrated progress toward the intended results. Global Fund Trustee: This manages the organization’s money, which includes making payments to recipients at the instruction of the Secretariat. The trustee is currently the World Bank. Local Fund Agent (LFA): Since the Global Fund does not have staff at the country level, it contracts firms to act as LFAs to monitor implementation. LFAs are responsible for providing recommendations to the Secretariat on the capacity of the entities chosen to manage Global Fund financing and on the soundness of regular requests for the disbursement of funds and result reports submitted by Principal Recipients. 31 Appendix E Appendix E. Members of the Global Fund Board Constituency Member Position Organization/Country Chair Mr. Simon Bland Deputy Director Department for International Development Vice Chair Ms. Mphu Ramatlapeng Minister of Health and Social Government of Lesotho Welfare Donor Governments European Commission Mr. Kristian Schmidt Director of Human and European Commission (Belgium, Finland, Portugal) Society Development DG for Development and Cooperation DEVCO France Amb. Patrice Debré Ambassador for the Fight Ministry of Foreign and against HIV and European Affairs, France Communicable Diseases Germany (Canada, Dr. Reinhard Tittel-Gronefeld Head of Division, Health, Federal Ministry for Switzerland) Population Policies Economic Cooperation and Development (BMZ), Germany Italy and Spain Ms. Elisabetta Belloni Director General-Directorate Ministry of Foreign Affairs, General for Development Italy Cooperation Japan Mr. Masaya Fujiwara Deputy Director General for International Cooperation Global Issues Bureau, Ministry of Foreign Affairs, Japan Point Seven (Denmark, Dr. Martin Greene Consultant to Irish Aid Ireland Ireland, Luxemburg, Netherlands, Norway, Sweden) United Kingdom and Carlton Evans Programme Manager United Kingdom Australia Department for International Development United States Amb. Eric Goosby U.S. Global AIDS Office of the U.S. Global Coordinator AIDS Coordinator, United States Recipient Governments Eastern and Southern Africa Minister Moina Fouraha Ministère de la Santé, de la Union of the Comoros Ahmed Solidarité, de la Cohésion sociale et de la Promotion du Genre Eastern Europe Dr. Viorel Soltan Deputy Minister of Health Republic of Moldova Ministry of Health Eastern Mediterranean Amb. Abdulkarim Yehia Minister of Public Health Ministry of Public Health and Region Rasae Population, Yemen Appendix E 32 Constituency Member Position Organization/Country Latin America and Caribbean Minister Leslie Ramsammy Minister of Health Guyana South East Asia Minister Rajendra Mahato Minister Nepal Ministry for Health and Population West and Central Africa Prof. Georges Marius Moyen Minister Ministry of Health and Population, Congo Western Pacific Region Dr. Huang Jiefu Vice-Minister of Health Ministry of Health, China Civil Society, Private Sector, Private Foundations, and Communities Communities Mr. Shaun Mellors Head: Treatment, Care and South Africa Support Department - Treatment Cluster Foundation for Professional Treatment Developed Country NGOs Mr Alvaro Bermejo Executive Director International HIV/ AIDS Executive Director Alliance United Kingdom Developing Country NGOs Dr. Cheikh Tidiane Tall Executive Director African Council of AIDS Service Organizations, Senegal Private Foundations Dr. Ernest Loevinsohn Director, Global Health Bill and Melinda Gates Policy and Advocacy Foundation, United States Private Sector Dr. Brian Brink Chief Medical Officer Anglo American plc, South Africa Ex Officio Members without Voting Rights Global Fund to Fight AIDS, Prof. Michel Kazatchkine Executive Director Global Fund, Switzerland Tuberculosis and Malaria Partners (Roll Back Malaria, Dr. Lucica Ditiu Executive Secretary Stop TB Partnership Stop TB, UNITAID) Secretariat, Switzerland UNAIDS Mr. Michel Sidibé Executive Director UNAIDS, Switzerland WHO Dr. Hiroki Nakatani Assistant Director General, World Health Organization, HIV/AIDS, TB Malaria and Switzerland Tropical Diseases World Bank Mr. Axel van Trotsenburg Vice President, Concessional World Bank Finance and Global Partnerships Board Designated Non- Mr. Edmond Tavernier Managing Partner Tavernier Tschanz Voting Swiss Member (Avocates: Attorneys-at- Law), Switzerland Source: Global Fund, www.theglobalfund.org/en/board/members/?lang=en 33 Appendix F Appendix F. Global Fund: Sources and Uses of Funds Table F-1. Global Fund: Income and Expenditures (US$ millions, calendar years) 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share Income Contributions 880.82 1,416.65 1,254.69 1,430.33 2,429.64 2,963.75 3,714.20 2,590.44 2,328.97 19,009.47 95.1% Contributions received, incl. 1,330.86 1,101.01 1,584.34 1,652.78 2,853.37 2,830.71 2,987.26 2,928.64 encashed promissory notes   Increase in promissory 10.62 174.99 -168.48 350.44 76.74 13.52 111.08 85.24 notes to be encashed   Increase/(decrease) in 75.17 -28.58 2.64 417.31 32.05 869.13 -508.49 -689.97 contributions receivable   Deferred revenue released 3.50 in Statement of Activities   Contributions in kind 0.00 7.27 11.83 9.11 1.60 0.84 0.58 1.57 Foreign currency exchange 0.00 0.00 0.00 0.00 -50.87 -83.71 124.83 -97.15 -106.90 -0.5% gain (loss)   Bank and trust fund income 10.08 28.24 33.82 58.94 126.50 240.50 289.72 150.40 149.68 1,087.88 5.4% Total Income 890.89 1,444.89 1,288.51 1,489.27 2,556.13 3,153.38 3,920.21 2,865.67 2,381.50 19,990.46 100.0% Expenditures Grants disbursed during the 0.90 231.20 627.51 1,054.33 1,306.97 1,710.81 2,259.25 2,749.46 3,060.68 13,001.10 92.7% year Employment costs 2.75 9.79 16.85 25.05 30.63 41.05 71.65 91.68 107.06 396.53 2.8% Other Secretariat expenses 7.02 10.77 19.57 27.29 28.92 41.07 63.13 74.78 90.34 362.88 2.6% Administrative services fee 0.86 0.90 0.98 0.99 2.09 1.97 2.51 - - 10.30 0.1% Communication materials 0.14 0.97 7.73 8.87 1.22 2.57 4.02 3.73 4.42 33.65 0.2% Office rental 0.43 0.51 0.75 1.04 2.20 4.68 7.14 7.64 8.24 32.63 0.2% Office infrastructure costs 0.61 1.00 1.42 3.49 2.11 5.04 10.97 16.45 27.54 68.64 0.5% Travel and meetings 1.03 3.75 4.67 5.93 8.19 10.93 12.34 18.54 19.53 84.90 0.6% Other professional services 3.33 2.08 3.52 5.99 12.18 15.00 24.79 27.01 29.70 123.60 0.9% Other 0.63 1.57 0.49 0.99 0.93 0.87 1.37 1.42 0.90 9.17 0.1% Local Fund Agent fees 0.67 10.12 12.18 19.20 23.89 32.87 27.07 57.06 57.94 241.01 1.7% CCM funding 0.00 0.00 0.00 0.00 0.00 0.00 1.40 2.20 4.11 7.70 0.1% Board constituency funding 0.63 0.63 0.0% Trustee fee 2.32 1.87 2.15 2.30 2.40 2.25 2.40 2.55 2.70 20.94 0.1% Appendix F 34 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share Foreign currency (gain)/loss 0.00 0.00 0.00 0.00 0.00 13.56 -4.94 -7.48 -35.75 -34.61 -0.2% Uncollectible contributions 0.00 0.00                1.10 26.73 27.83 0.2% Total Expenditures 13.67 263.76 678.25 1,128.17 1,392.82 1,841.61 2,419.95 2,971.36 3,314.43 14,024.01 100.0% Income - Expenditures 877.23 1,181.13 610.25 361.11 1,163.32 1,311.78 1,500.26 -105.69 -932.93 5,966.45 Movement in undisbursed 51.12 832.10 226.86 454.95 510.46 871.66 110.50 1,248.81 160.48 grants a Source: Global Fund Annual Reports, 2002/2003 to 2010. a. The annual change in the value of grant commitments that have not yet been disbursed. Table F-2. World Bank Expenditures and Disbursements (Constant 2010 US$ millions) Type of Funding / Fiscal Year FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 Total Share Bank lending and grant disbursements IBRD 14,478 14,774 12,034 11,311 13,322 11,845 11,104 18,935 28,711 136,514 51.6% IDA 8,491 8,643 8,247 10,300 9,999 9,184 9,641 9,468 11,423 85,396 32.3% Recipient-executed trust funds 923 1,193 1,379 1,714 1,636 2,305 2,742 2,895 2,615 17,401 6.6% DGF & other below-the-line grants 176 156 179 173 173 171 176 200 170 1,574 0.6% Subtotal 24,067 24,766 21,839 23,498 25,131 23,505 23,662 31,498 42,919 240,886 91.0% Administrative expenses Bank budget actual a 1,977 2,043 2,240 2,339 2,342 2,247 2,244 2,213 2,301 19,946 6.9% Reimbursements and fee income b 200 213 223 234 238 257 255 297 314 2,231 0.8% Bank-executed trust funds 242 275 321 347 357 420 442 481 575 3,460 1.2% Subtotal 2,419 2,531 2,783 2,921 2,937 2,925 2,940 2,990 3,190 25,636 9.0% Total disbursements/expenditures 26,310 27,141 24,443 26,246 27,895 26,258 26,427 34,289 45,938 264,948 100.0% Share of administrative expenditures 8.5% 8.7% 10.5% 10.4% 9.8% 10.3% 10.3% 8.0% 6.4% 9.0% Source: World Bank databases. a. Bank budget actual is equal to the Bank's gross administrative budget, financed from the Bank’s own resources, not including the Development Grant Facility and other below- the-line grants. b. Reimbursements and fee income are additional sources of revenue that are comingled with other administrative expenses spent by the Bank to help facilitate the disbursement of loans, credits, and grants to client countries. c. Bank-executed trust funds are a third source of revenue that supports the Bank’s work program and that are also comingled with other administrative expenses. 35 Appendix F a Table F-3. Global Fund: Annual Contributions by Donor (US$ millions, calendar years) Country 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share United States 275.0 347.7 458.9 352.0 463.7 642.3 789.2 1,010.1 791.3 5,130.2 27.2% France b 59.0 63.8 191.4 181.0 281.3 409.8 434.8 431.9 378.0 2,431.0 12.9% Japan 80.4 80.0 86.1 100.0 130.1 186.0 183.8 194.4 246.9 1,287.8 6.8% Germany 12.0 37.4 45.9 103.0 88.1 116.7 312.2 271.4 269.2 1,255.9 6.7% United Kingdom c, d 78.2 40.0 60.3 96.0 198.4 187.2 78.5 182.1 319.1 1,239.8 6.6% European Commission - 137.1 314.8 69.1 117.2 91.1 127.0 285.2 62.7 1,204.0 6.4% Italy 108.6 106.5 - 217.8 - 575.3 - - - 1,008.3 5.3% Canada 25.0 25.0 50.0 110.3 221.2 - 102.0 35.4 276.1 845.0 4.5% Spain - 35.0 15.0 - 80.2 104.8 138.9 207.4 137.8 719.1 3.8% Gates Foundation d 50.0 50.0 50.0 - 100.0 100.0 100.0 209.5 10.5 670.0 3.6% Netherlands - 51.7 54.3 56.1 76.8 82.7 114.2 83.5 82.8 602.1 3.2% Sweden 22.4 11.5 41.3 55.9 82.3 64.5 140.1 50.0 74.0 542.1 2.9% Norway 18.0 17.7 17.9 23.6 43.1 50.2 52.6 67.2 62.0 352.2 1.9% Russian Federation 1.0 4.0 5.0 10.0 10.0 75.3 50.7 79.0 22.0 257.0 1.4% Denmark 14.8 13.8 16.2 22.8 23.9 25.9 29.4 31.9 31.2 209.9 1.1% Australia - - 13.8 15.0 12.7 15.3 38.9 32.8 42.5 171.0 0.9% WHO d - 0.2 - - - - 38.7 65.0 65.0 168.9 0.9% Global Fund e - - - - 11.0 46.7 39.7 42.9 25.5 165.9 0.9% Ireland 13.0 8.0 12.3 17.1 26.3 27.4 30.9 14.0 11.5 160.6 0.9% Belgium 9.4 2.8 17.5 6.1 10.3 16.6 15.9 17.9 32.4 128.9 0.7% U.N. Foundation - 4.3 0.3 - - - 45.6 0.0 5.3 55.4 0.3% Switzerland 3.1 6.9 2.3 3.9 4.9 5.7 6.7 6.3 7.2 47.1 0.2% Saudi Arabia - 2.5 2.5 2.5 2.5 - 6.0 6.0 6.0 28.0 0.1% Luxembourg - 2.1 2.4 2.5 3.5 3.1 3.9 3.3 3.2 24.0 0.1% Indonesia - - - - - - 8.0 7.2 8.1 23.4 0.1% Finland - - - - 3.6 3.3 3.9 4.9 4.4 20.2 0.1% Nigeria 9.1 - - - - - - - 10.0 19.0 0.1% China - 2.0 2.0 2.0 2.0 2.0 2.0 2.0 2.0 16.0 0.1% Pakistan - - - - - - - 6.9 6.1 13.1 0.1% Korea - - 0.5 0.3 0.3 3.0 3.0 4.0 2.0 13.0 0.1% Portugal - 0.4 0.6 1.5 2.0 3.0 3.0 - 2.5 13.0 0.1% South Africa - - 2.0 2.0 2.0 2.0 0.1 2.1 - 10.3 0.1% India - - - - 1.0 1.5 0.5 2.0 5.0 10.0 0.1% Appendix F 36 Country 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share Thailand - 2.0 - 2.0 0.0 2.0 - 2.0 1.0 9.0 0.0% New Zealand - 0.7 0.6 0.8 - - - - 0.7 2.8 0.0% Greece - - - 0.3 - 0.5 - 1.4 - 2.2 0.0% Tunisia - - - - - - - - 2.0 2.0 0.0% Kuwait - - - - - - 1.0 0.5 - 1.5 0.0% Uganda - - 0.5 0.5 0.5 - - - - 1.5 0.0% Iceland - - 0.2 - 0.2 0.4 - 0.3 - 1.1 0.0% Austria - 1.1 - - - - - - - 1.1 0.0% Singapore - - 0.2 0.2 0.2 0.2 0.2 - - 1.0 0.0% Liechtenstein 0.1 - 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.8 0.0% Romania - - - - - 0.4 0.1 0.1 0.1 0.7 0.0% Côte d'Ivoire - - - - - - - - 0.7 0.7 0.0% Slovenia - - - 0.0 0.0 0.0 0.1 0.1 0.1 0.3 0.0% Mexico - - - 0.1 0.1 - - - - 0.2 0.0% Zimbabwe - 0.2 - - - - - - - 0.2 0.0% Poland - 0.0 0.0 0.0 0.0 - 0.1 - - 0.2 0.0% Brazil - - - - 0.2 - - - - 0.2 0.0% Monaco 0.0 0.0 0.0 - - - - - - 0.1 0.0% Andorra 0.1 - - - - - - - - 0.1 0.0% Barbados - - 0.1 - - - - - - 0.1 0.0% Burkina Faso 0.1 - - - - - - - - 0.1 0.0% Hungary - - 0.0 0.0 0.0 - 0.0 - - 0.1 0.0% Brunei Darussalam - - - - - - - 0.0 - 0.0 0.0% Latvia - - - - - - 0.0 - - 0.0 0.0% Total 779.3 1,054.5 1,465.2 1,454.4 1,999.8 2,845.0 2,902.0 3,361.0 3,006.8 18,868.0 100.0% a. The Global Fund Trust Fund is maintained in US dollars and Euro (the "Holding Currencies"). The contributions maintained in Euro are converted to US dollars at the euro/US$ exchange rate as of December 31 each year." b. Annual contributions include the euro amount of Promissory Notes contributed and not encashed as of December 31, 2010. The encashed Promissory Notes are reflected as contributions in the year when the respective Promissory Notes were issued. c. Annual contributions include the U.S. dollar equivalent amount of Promissory Notes contributed and not encashed (outstanding) as of December 31, 2010. The U.S. equivalent amount of outstanding Promissory Notes is calculated using the US$/GBP exchange rate as of December 31 of the year when those Promissory Notes were issued. The encashed Promissory Notes are reflected as contributions in the year when the respective Promissory Notes were issued. d. Includes the contributions to the Affordable Medicines Facility for Malaria (AMFm). e. These are contributions collected by the Global Fund Secretariat from various donors or from (Product) RED partners and passed on to the trustee. 37 Appendix F Table F-4. Official Development Assistance and Other Official Flows from OECD/DAC Member Countries and Multilateral Agencies to Developing Countries a. Commitments to HIV/AIDS, Tuberculosis, and Malaria (US$ millions, constant 2008 prices) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total Global Fund 0.0 0.0 0.0 1,294.6 977.0 1,667.2 1,979.4 2,643.0 2,213.2 4,223.5 14,997.9 IBRD/IDA 187.5 240.3 306.3 374.1 265.2 221.4 324.3 218.5 317.4 233.0 2,688.2 Other donors 996.3 1,121.5 1,393.9 2,109.9 2,283.5 3,454.7 4,113.9 5,839.6 6,637.8 6,894.0 34,845.3 Total 1,183.8 1,361.8 1,700.2 3,778.6 3,525.7 5,343.3 6,417.7 8,701.1 9,168.4 11,350.5 52,531.3 Share of Total Global Fund 0% 0% 0% 34% 28% 31% 31% 30% 24% 37% 29% IBRD/IDA 16% 18% 18% 10% 8% 4% 5% 3% 3% 2% 5% Other donors 84% 82% 82% 56% 65% 65% 64% 67% 72% 61% 66% b. Commitments to Health, Nutrition and Population (US$ Millions, constant 2008 prices) 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total Global Fund 0.0 0.0 0.0 1,294.6 980.7 1,683.8 2,034.7 2,643.0 2,232.8 4,308.5 15,178.1 IBRD/IDA 1,674.6 2,653.0 1,943.1 3,528.6 2,074.7 1,618.9 2,931.2 1,412.0 2,272.4 2,642.2 22,750.8 Other donors 5,873.6 6,479.1 7,262.9 8,236.6 8,457.4 10,525.7 12,687.6 13,866.4 14,912.9 15,419.0 103,721.1 Total 7,548.1 9,132.2 9,206.0 13,059.7 11,512.8 13,828.4 17,653.4 17,921.4 19,418.2 22,369.6 141,649.9 Share of Total Global Fund 0% 0% 0% 10% 9% 12% 12% 15% 11% 19% 11% IBRD/IDA 22% 29% 21% 27% 18% 12% 17% 8% 12% 12% 16% Other donors 78% 71% 79% 63% 73% 76% 72% 77% 77% 69% 73% Source: OECD. Official Development Assistance represents concessional flows including IDA. Other Official Flows are non-concessional flows, such as lending by IBRD and regional development banks. a. This data was obtained on March 25, 2011. The source codes for HIV/AIDS, tuberculosis, and malaria were 13040, Malaria (12262), TB (12263), and HIV/Aids (13040) Appendix F 38 Table F-5. Global Fund: Grant Commitments by Region (US$ millions, calendar years) Region 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share Sub-Saharan Africa: East Africa 78.1 723.7 497.0 1,142.2 305.6 126.3 373.2 613.6 466.7 4,326.4 25% Sub-Saharan Africa: West & Central Africa 19.9 166.6 330.4 240.4 427.3 269.3 158.6 709.4 635.2 2,956.9 17% Sub-Saharan Africa: Southern Africa 754.3 405.3 450.6 144.7 192.6 191.7 390.9 81.6 2,611.7 15% East Asia & the Pacific 551.3 335.0 260.7 215.7 202.5 108.7 271.7 541.7 2,487.3 14% South Asia 12.7 53.0 414.3 290.4 61.3 224.8 100.9 93.7 231.2 1,482.3 8% Eastern Europe & Central Asia 194.5 295.4 259.5 61.2 263.6 60.5 123.8 115.5 1,374.1 8% Latin America & the Caribbean 129.7 211.5 262.9 93.7 109.5 84.9 105.0 105.0 100.3 1,202.4 7% North Africa & the Middle East 26.1 118.8 198.2 162.0 143.0 147.9 114.4 128.7 1,039.1 6% Total 240.4 2,681.1 2,659.1 2,935.6 1,487.3 1,507.1 1,246.4 2,422.4 2,300.9 17,480.3 100% Table F-6. Global Fund: Grant Disbursements by Region (US$ millions, calendar years) Region 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share Sub-Saharan Africa: East Africa 66.2 137.8 295.0 379.9 420.7 567.1 586.8 883.6 3,337.1 26% Sub-Saharan Africa: West & Central Africa 0.9 19.2 74.1 149.4 175.0 218.7 292.5 560.7 458.7 1,949.2 15% Sub-Saharan Africa: Southern Africa 37.1 118.0 167.3 154.4 301.6 371.9 361.3 404.1 1,915.7 15% East Asia & the Pacific 45.7 103.3 137.1 194.7 220.3 279.6 398.7 453.0 1,832.4 14% Eastern Europe & Central Asia 21.5 57.6 91.6 143.2 201.6 204.4 215.5 212.0 1,147.4 9% South Asia 6.1 29.1 31.0 80.4 144.4 210.0 284.9 276.4 1,062.2 8% Latin America & the Caribbean 32.2 79.2 114.2 110.0 130.4 171.1 184.3 169.5 991.0 8% North Africa & the Middle East 3.1 28.4 66.6 84.3 89.0 157.0 163.1 192.2 783.7 6% Total 0.9 231.2 627.5 1,052.3 1,321.8 1,726.7 2,253.5 2,755.1 3,049.6 13,018.7 100% 39 Appendix F Table F-7. Global Fund: Grant Commitments by Disease (US$ millions, calendar years) Region 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share HIV/AIDS 143.9 1,835.0 1,774.8 1,732.8 671.3 842.2 631.7 889.2 1,012.2 9,533.2 55% Malaria 85.3 334.2 456.5 895.2 347.7 337.6 469.3 1,296.4 649.3 4,871.5 28% Tuberculosis 11.2 402.7 326.4 249.3 412.9 327.3 145.4 235.9 627.7 2,738.8 16% HIV/tuberculosis 109.1 98.3 24.4 231.8 1% HSS 33.9 55.5 0.8 11.7 102.0 1% Integrated 3.1 3.1 0% Total 240.4 2,681.1 2,659.1 2,935.6 1,487.3 1,507.1 1,246.4 2,422.4 2,300.9 17,480.3 100% Table F-8. Global Fund: Grant Disbursements by Disease (US$ millions, calendar years) Region 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Share HIV/AIDS 0.4 121.1 360.8 578.1 692.8 1,073.6 1,334.7 1,295.2 1,573.1 7,029.8 54% Malaria 49.5 135.5 308.2 407.5 351.4 521.2 1,017.2 919.0 3,709.6 28% Tuberculosis 0.5 40.7 107.2 127.2 195.7 276.2 316.8 387.0 511.8 1,963.0 15% HIV/tuberculosis 19.9 22.2 30.1 18.4 21.9 52.3 18.5 12.2 195.7 2% HSS 8.2 6.5 3.7 28.5 37.3 33.4 117.5 1% Integrated 1.7 0.5 1.0 3.1 0% Total 0.9 231.2 627.5 1,052.3 1,321.8 1,726.7 2,253.5 2,755.1 3,049.6 13,018.7 100% Appendix F 40 Table F-9. Global Fund: Grant Commitments by Disease (US$ millions, World Bank fiscal years) 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Share HIV/AIDS 1,050.2 1,662.3 2,617.8 238.6 670.9 793.3 578.3 1,069.0 1,232.9 9,913.3 54% Malaria 212.1 352.9 1,135.2 303.9 162.8 478.8 573.6 1,314.5 631.1 5,164.9 28% Tuberculosis 329.6 232.9 285.5 262.9 349.4 274.8 188.7 324.0 625.1 2,872.9 16% HIV/tuberculosis 26.3 70.0 81.6 24.4 202.3 1% HSS 33.9 55.5 0.8 68.8 159.1 1% Integrated 3.1 3.1 0% Total 1,618.3 2,318.1 4,123.2 863.7 1,238.6 1,547.0 1,340.6 2,708.3 2,557.9 18,315.6 100% Table F-10. Global Fund: Grant Disbursements by Disease (US$ millions, World Bank fiscal years) 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Share HIV/AIDS 20.5 216.0 534.3 480.5 889.7 1,231.0 1,222.7 1,542.5 1,333.1 7,470.3 53% Malaria 6.7 82.5 209.8 386.3 352.3 424.3 477.6 1,215.2 896.8 4,051.6 29% Tuberculosis 6.4 67.7 122.3 145.7 222.4 325.8 318.3 406.0 512.5 2,127.1 15% HIV/tuberculosis 1.7 21.6 27.5 36.4 6.5 46.5 37.0 18.4 (0.4) 195.2 1% HSS 8.2 9.4 10.6 22.7 36.4 83.6 170.9 1% Integrated 1.7 0.9 0.5 3.1 0% Total 35.3 387.8 895.6 1,058.1 1,480.9 2,038.3 2,078.3 3,218.5 2,825.6 14,018.3 100% 41 Appendix F Table F-11. World Bank: Project Commitments by Health Theme (US$ millions, fiscal years) Theme 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Share Health system performance 575.2 556.5 483.6 520.3 747.0 461.5 1,387.9 3,234.3 1,393.2 9,359.5 43% Child health 232.1 410.4 202.2 200.1 390.7 106.7 625.7 147.9 329.0 2,644.9 12% HIV/AIDS 325.2 210.3 243.0 87.2 313.7 50.8 218.3 127.4 152.4 1,728.2 8% Population & reproductive health 196.7 296.3 194.2 135.8 342.6 79.0 92.2 149.5 242.4 1,728.8 8% Injuries & non-communicable diseases 159.6 314.7 330.9 197.8 477.6 17.5 43.4 55.8 148.4 1,745.8 8% Nutrition & food security 199.7 32.0 141.4 74.9 136.6 82.3 231.4 76.5 143.1 1,118.0 5% Tuberculosis 91.1 49.7 66.7 25.5 80.2 11.6 22.5 41.8 25.3 414.3 2% Other communicable diseases 8.0 45.6 33.8 71.3 84.0 22.1 91.4 383.3 98.3 837.9 4% Malaria 7.6 9.1 7.3 117.8 77.6 76.5 260.9 26.0 146.8 729.6 3% Other human development 69.6 133.5 165.8 142.3 214.6 44.7 112.1 220.8 226.5 1,330.0 6% Total 1,864.8 2,058.1 1,869.0 1,573.0 2,864.6 952.5 3,085.9 4,463.4 2,905.6 21,636.8 100% Subtotal mapped to the 912.9 1,366.9 921.2 782.8 1,535.0 683.1 1,492.4 3,080.1 2,089.3 12,863.7 59% HNP Sector Board Source: World Bank data. Note: Each World Bank project can identify up to five themes promoted by the project. World Bank commitments represent the proportions of total project commitments to each theme. The subtotal “mapped to the HNP Sector Board� represents the share of these commitments under the control of the HNP Sector Board. That is, each Bank-supported project is supervised by a project manager who reports to a regional manager, who is represented on a Bank-wide sector board. Each project is thereby “mapped� — or becomes the responsibility of — that sector board, in this case the HNP Sector Board. Appendix F 42 Table F-12. World Bank: Project Disbursements by Health Theme (US$ millions, fiscal years) Theme 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Share Health system performance 558.0 514.1 409.3 525.5 545.1 418.6 771.4 1,587.4 1,705.7 7,035.1 42% Child health 167.1 355.0 181.6 153.6 173.7 152.0 196.3 298.2 194.0 1,871.6 11% HIV/AIDS 68.7 116.3 178.3 238.9 221.3 235.8 168.2 178.7 158.2 1,564.5 9% Population & reproductive 156.4 268.8 184.7 143.1 154.7 145.8 166.4 150.8 170.9 1,541.6 9% health Injuries & non-communicable 12.5 20.0 51.0 160.9 186.9 204.4 223.8 237.0 160.6 1,257.0 8% diseases Nutrition & food security 99.8 101.9 131.9 152.8 94.5 97.1 154.3 165.9 83.2 1,081.5 6% Tuberculosis 43.0 72.0 83.9 115.5 92.5 87.1 59.7 57.4 50.4 661.6 4% Other communicable 40.3 32.0 34.2 33.1 44.5 67.5 36.4 75.1 62.9 426.1 3% diseases Malaria 16.4 20.0 10.5 15.3 45.5 61.0 49.3 70.7 55.1 343.8 2% Other human development 29.1 16.3 43.3 34.3 71.1 144.4 81.7 213.5 270.3 903.9 5% Total 1,191.3 1,516.3 1,308.9 1,573.0 1,630.0 1,613.7 1,907.6 3,034.7 2,911.2 16,686.7 100% Subtotal mapped to the 606.7 1,185.5 834.0 866.6 940.1 902.3 875.9 1,192.1 1,741.0 9,144.1 55% HNP Sector Board Source: World Bank data. Note: Each World Bank project can identify up to five themes promoted by the project. World Bank disbursements represent the proportions of total project disbursements to each theme. The subtotal “mapped to the HNP Sector Board� represents the share of these disbursements under the control of the HNP Sector Board. That is, each Bank-supported project is supervised by a project manager who reports to a regional manager, who is represented on a Bank-wide sector board. Each project is thereby “mapped� — or becomes the responsibility of — that sector board, in this case the HNP Sector Board. 43 Appendix F Table F-13. Global Fund and World Bank, Commitments and Disbursements by Country, Fiscal Years 2003–11 Inclusive (US$ millions) Global Fund World Bank Region/Country Commitments Disbursements Commitments Disbursements Africa 11,131.2 8,371.9 3,934.8 3,595.0 East Asia and the Pacific 2,611.9 1,984.2 1,277.3 1,159.7 Europe and Central Asia 1,438.7 1,264.7 2,592.5 2,223.5 Latin America and the Caribbean 1,364.9 1,114.5 7,692.2 5,484.2 South Asia 1,505.9 1,068.8 3,359.1 2,777.2 Middle East and North Africa 263.0 214.2 301.8 513.9 World - - 11.9 1.9 Total 18,315.6 14,018.3 19,169.6 15,755.3 Africa 11,131.2 8,371.9 3,934.8 3,595.0 Ethiopia 1,314.7 1,062.8 284.9 328.4 Tanzania 887.5 683.6 274.6 311.0 Nigeria 762.7 528.5 560.9 502.9 Rwanda 631.3 453.8 65.4 66.2 Malawi 548.2 413.2 54.0 30.4 Zambia 456.0 381.1 60.4 47.2 Congo, Democratic Republic of 531.3 378.1 407.1 296.0 Sudan 397.2 309.4 161.1 82.4 Kenya 317.2 282.2 178.5 98.5 Ghana 351.0 273.9 267.1 286.7 Uganda 352.8 262.3 297.7 236.9 Zimbabwe 288.1 244.1 - - South Africa 292.7 234.2 - - Mozambique 351.1 223.5 124.1 52.9 Cameroon 247.3 202.2 31.2 35.3 Madagascar 230.9 172.4 111.7 162.0 Burkina Faso 186.7 161.3 135.1 125.5 Namibia 201.2 148.0 - - Côte d'Ivoire 279.5 138.9 11.2 15.6 Angola 171.5 130.8 92.4 13.5 Swaziland 141.0 121.9 16.4 - Togo 161.2 116.5 4.1 3.8 Burundi 152.2 115.0 68.3 73.4 Benin 176.6 111.2 88.0 81.6 Somalia 122.9 103.0 0.5 0.8 Eritrea 111.5 100.6 16.1 66.7 Senegal 139.8 99.1 57.0 121.0 Niger 116.5 95.0 94.2 93.8 Lesotho 146.5 90.7 27.2 17.4 Mali 126.0 89.7 50.0 80.8 Liberia 105.7 84.8 8.4 5.9 Gambia, The 90.0 79.4 4.5 30.6 Sierra Leone 100.6 66.8 63.1 64.1 Central African Republic 93.1 62.5 1.2 8.6 Chad 96.8 55.6 23.8 61.7 Congo, Republic of 89.9 38.5 41.9 26.3 Appendix F 44 Global Fund World Bank Region/Country Commitments Disbursements Commitments Disbursements Multicountry Africa (RMCC) 47.6 36.2 - - Guinea 57.0 34.7 25.2 17.9 Guinea-Bissau 33.0 31.7 7.4 16.2 Gabon 37.9 29.7 - - Equatorial Guinea 32.9 28.2 - - Multicountry Africa (West Africa 31.4 23.6 - - Corridor Program) Mauritania 29.5 16.2 11.5 25.2 Zanzibar 20.9 15.9 - - Botswana 26.9 15.0 46.5 8.8 Comoros 11.7 9.2 2.5 7.3 Sao Tome and Principe 10.0 7.7 3.4 2.1 Mauritius 5.0 4.1 - - Cape Verde 5.0 2.8 8.7 19.1 Multicountry Africa (SADC) 13.2 2.1 - - Africa - - 147.4 70.6 East Asia and the Pacific 2,611.9 1,984.2 1,277.3 1,159.7 China 834.5 559.6 150.1 228.7 Indonesia 391.3 341.9 264.0 370.1 Thailand 269.3 249.9 0.5 0.8 Cambodia 323.4 242.4 39.2 35.0 Philippines 188.1 167.3 274.8 167.7 Vietnam 142.4 100.2 475.6 286.9 Lao People's Democratic 95.3 77.9 42.1 30.3 Republic Papua New Guinea 103.4 72.4 - 1.0 Multicountry Western Pacific 61.9 52.4 - - Myanmar 105.4 47.6 0.5 0.5 Mongolia 25.8 25.8 0.8 0.8 Korea, Democratic People’s 32.8 21.7 - - Republic of Timor-Leste 24.9 19.9 13.5 18.7 Fiji 5.2 3.5 - - Solomon Islands 4.0 1.6 0.2 2.5 Malaysia 4.3 - - - Tonga - - 10.6 11.7 Samoa - - 5.3 5.2 Europe and Central Asia 1,438.7 1,264.7 2,592.5 2,223.5 Russian Federation 367.7 361.4 174.0 147.9 Ukraine 257.4 217.4 45.0 38.9 Tajikistan 82.9 81.1 29.6 24.5 Kazakhstan 84.3 73.0 97.7 18.1 Romania 64.8 63.6 95.7 76.1 Georgia 68.6 55.8 48.7 61.7 Moldova 60.9 51.2 21.7 26.2 Uzbekistan 61.5 50.8 136.7 52.8 Bulgaria 60.5 50.4 195.4 203.8 Belarus 59.1 48.2 - - Kyrgyz Republic 52.7 45.4 31.5 26.6 45 Appendix F Global Fund World Bank Region/Country Commitments Disbursements Commitments Disbursements Azerbaijan 52.7 38.5 45.0 20.7 Serbia 29.2 26.5 55.5 48.0 Armenia 31.4 23.1 83.1 68.8 Bosnia and Herzegovina 38.7 21.4 26.4 21.5 Macedonia, former Yugoslav 16.0 15.5 34.6 36.5 Republic of Estonia 10.5 10.5 - - Montenegro 7.9 7.1 15.7 7.3 Kosovo 11.7 6.7 1.7 3.2 Albania 6.2 5.6 32.1 28.1 Croatia 4.9 4.9 90.0 79.8 Turkmenistan 5.9 3.4 1.0 1.0 Turkey 3.3 3.3 668.0 641.3 Poland - - 433.6 453.9 Slovak Republic - - 54.7 60.3 Latvia - - 87.2 41.4 Lithuania - - - 16.7 Central Asia - - 17.5 16.3 Slovenia - - - 2.1 Hungary - - 70.7 Latin American and the 1,364.9 1,114.5 7,692.2 5,484.2 Caribbean Haiti 253.9 199.8 21.0 6.5 Peru 134.5 123.2 470.2 220.7 Dominican Republic 109.5 97.1 203.0 201.8 Cuba 86.7 72.5 - - Honduras 104.9 70.2 9.7 45.9 Guatemala 68.9 64.0 90.5 26.9 El Salvador 54.3 51.7 45.7 171.4 Nicaragua 53.4 48.9 55.2 48.5 Jamaica 55.7 46.8 31.7 33.5 Brazil 50.6 38.4 1,490.9 959.3 Guyana 47.1 38.1 7.6 8.0 Chile 43.0 37.1 10.0 10.0 Ecuador 46.6 30.3 104.9 41.8 Multicountry Americas (Andean) 28.8 28.8 - - Bolivia (Plurinational State) 43.7 26.0 36.9 68.9 Colombia 25.0 25.0 706.9 758.3 Argentina 29.3 24.0 2,389.0 1,456.7 Paraguay 23.9 23.9 12.1 4.6 Multicountry Americas 19.2 17.3 - - (COPRECOS) Multicountry Americas 21.5 14.3 - - (CARICOM / PANCAP) Suriname 23.7 10.2 - - Multicountry Americas (Meso) 8.4 8.4 - - Costa Rica 4.0 4.0 - 13.3 Belize 3.6 3.6 3.5 0.6 Multicountry Americas (REDCA+) 5.3 3.1 - - Appendix F 46 Global Fund World Bank Region/Country Commitments Disbursements Commitments Disbursements Multicountry Americas (CRN+) 3.9 2.9 - - Panama 2.6 2.6 69.1 42.5 Multicountry Americas (OECS) 12.5 1.9 - - Mexico 0.6 0.6 1,743.2 1,243.3 Uruguay - - 113.4 58.3 Barbados - - 35.0 22.0 Trinidad and Tobago - - 20.0 20.0 Central America - - 6.0 6.0 Grenada - - 5.5 3.8 Venezuela, Republica Bolivariana - - - 3.4 de St. Kitts and Nevis - - 2.9 2.3 Caribbean - - 2.3 2.1 St. Vincent and the Grenadines - - 2.0 1.8 St. Lucia - - 3.9 1.8 Latin America - - 0.1 - South Asia 1,505.9 1,068.8 3,359.1 2,777.2 India 901.0 642.6 1,732.3 1,754.9 Bangladesh 208.0 171.0 591.9 234.7 Pakistan 127.5 88.4 524.5 456.5 Nepal 93.4 63.1 233.1 125.1 Afghanistan 90.5 54.9 202.9 154.4 Sri Lanka 59.1 34.6 59.8 41.2 Bhutan 8.5 7.4 7.3 7.5 Multicountry South Asia 13.7 3.8 3.7 1.3 Maldives 4.1 2.9 3.6 1.6 Middle East and North Africa 263.0 214.2 301.8 513.9 Yemen, Republic of 49.7 40.0 86.6 70.6 Iran, Islamic Republic of 49.7 38.8 - 81.1 Morocco 38.3 33.0 20.9 61.2 Djibouti 23.5 21.3 14.2 25.2 Iraq 27.3 20.3 45.6 35.4 Egypt, Arab Republic of 22.1 16.5 75.0 108.5 Tunisia 19.9 16.5 0.9 22.8 Jordan 11.2 9.9 - 24.5 Algeria 6.9 6.9 - - West Bank and Gaza 6.3 5.2 56.6 64.4 Syrian Arab Republic 7.4 5.1 0.5 0.0 Lutheran World Federation 0.7 0.7 - - Lebanon - - 0.8 19.6 Middle East and North Africa 0.6 0.5 World - - 11.9 1.9 Totals 18,315.6 14,018.3 19,169.6 15,755.3 Source: Global Fund and World Bank data. See Appendix Table F-13. Note: World Bank commitments and disbursements represent the proportions of total project commitments and disbursements to the health sector. World Bank disbursements to a country can exceed commitments due to projects that were approved before FY03 and still disbursing in FY03–10. 47 Appendix G Appendix G. Global Fund Five-Year Evaluation: Major Findings, Recommendations, and Program Response2 Findings Recommendations Program Response 1. Mobilization of Resources The Global Fund, 1. The international development community needs to systematically address  Greater attention is placed on sustainability and resource together with major the requirements of sustainability in the global response to the three mobilization is emphasized to sustain Global Fund-supported partners, has pandemics. As part of this response, the Global Fund replenishment activities and achievements. mobilized impressive mechanism should further its mobilization of financial resources from  New resource mobilization strategy being implemented (including resources to support existing donors and new sources of funding, including from international diversifying funding sources, developing innovative finance the fight against AIDS, donor agencies that have not yet contributed and from nontraditional vehicles; achieving efficiency gains in grant portfolio and in tuberculosis, and sources. All Global Fund resources should meet the criterion of Secretariat operations). malaria. additionality—that is, they should be additional to existing AIDS,  Diversification includes stronger push in tapping private sector tuberculosis, and malaria funds and to the health sector overall. contributions. 2. The Global Fund should, in particular, increase its efforts to engage the private sector in the partnership, expanding the range and types of  For 2010, there will be zero growth of Secretariat staff and almost contributions, especially to mobilize in-country private-sector resources. zero growth of operational budget. 3. The Global Fund should work with other financing entities to help ensure the predictable multi-year funding required to maintain high-quality programs. This should be given urgent priority, especially in areas where the Global Fund has become the largest international donor. 2. Service Delivery Collective efforts have 4. The Global Fund’s business plan should increasingly differentiate its Grant portfolio and new grant architecture at the resulted in increases prevention and treatment approaches in specific countries based on the country level to improve service delivery in service availability, epidemiological profiles of AIDS, tuberculosis, and malaria and the  Move from a project-based approach to a single stream of funding better coverage, and assessment of a country’s capacity to execute its planned disease control mode. reduction of disease programs.  Support for National Strategy Applications. Instead of multiple burden. 5. The Global Fund should adjust its �demand-driven model� and focus its grants for one disease in a country, Global Fund support for the resources on prevention and treatment strategies that utilize the most national strategy for ONE disease, and all grants will be grouped 2. The FYE report was an important input to the replenishment process. Participants at the Third Replenishment Meeting in 2010 welcomed the updated report from Global Fund management on the implementation of the FYE recommendations and urged acceleration of the proposed reforms. Participants at the meeting underlined the importance of the reforms in areas of: the new grant architecture, the National Strategy Application, Accountability Framework, eligibility and prioritization of countries, and collaboration with other development partner agencies for more effective service delivery. Appendix G 48 Findings Recommendations Program Response cost-effective interventions that are tailored to the type and local context under it. of specific epidemics.  More emphasis to be placed on HSS, maternal and child health, 6. The Global Fund and its partners should continue to finance scale-up and the prevention of mother-to-child transmission of HIV/ AIDS. efforts, in particular for key malaria program interventions in light of the  The Secretariat acknowledged the importance of strengthening encouraging initial results from several countries and from research. and integrating national health information systems with Global 7. Much higher priority on the strengthening and integration of health Fund-supported programs. It reiterated strong support for information systems required by countries to manage their programs and achieving this objective. (See also the section on performance- monitor impact. Specifically: based funding.) a. The Global Fund and partners should reorient investments from disease-specific M&E toward strengthening the country health information systems required to maximize data quality and use for decision making. b. Countries should be encouraged to increase investment in medium- to long-term capacity building for financial tracking, including through the incorporation of health expenditure data in their population-based surveys and the completion of periodic national health account exercises. c. Countries should also be encouraged to emphasize the development of quality assurance mechanisms that can help to achieve urgently required financial oversight at the sub-recipient level. 3. Health Systems Strengthening Health systems in 8. The Global Fund and partners should address the major gaps in basic  In reference to past “friendship� or “loose� models of the Global most developing health service availability and readiness—the minimum components for Fund’s partnership arrangements, a New Partnership Strategy countries will need to delivery of quality services such as basic infrastructure, staffing, and was developed and approved by the Board in November 2009. It be greatly supplies—as part and parcel of scaling-up against the three diseases. In provided a framework for strategic division of labor, clarity of roles, strengthened if particular, Global Fund grants for HSS should support overall country and coordination and mechanisms for funding technical current levels of health sector strategic plans. assistance. Existing partnerships are being consolidated and services are to be 9. The Global Fund and its partners together should clarify, as a matter of strengthened, while new ones will be forged, with GAVI, the World significantly urgency, an operational division of labor regarding the provision and Bank, IHP +, and the HSS joint funding platform. The Global Fund expanded. financing of technical support for HSS. These efforts should take a longer- will actively participate in the IHP + and be part of the coordinated term perspective in delivering technical support. They should, in particular, response to scale up the fight against AIDS, tuberculosis, and support human-resource capacity building over a horizon of five to ten malaria. More effort will be spent strengthening health systems, years, in harmony with other global and regional initiatives. maternal and child health, and mother-to child transmission of 10. The Global Fund Secretariat should develop and articulate a strategy that AIDS. allows for a menu of investment approaches to increase the probability  Because “Global Fund donors have not explicitly articulated the that grants will perform well. The assessment of management issues as need (or approval) to providing complementary technical 49 Appendix G Findings Recommendations Program Response part of the grant rating should include explicit linkage to whether grant assistance funding through technical agencies (development technical support budgets are being used for necessary capacity-building partner agencies), the Secretariat is still trying to find innovative measures. In particular, for countries with weak health systems and/or high solutions for technical assistance coordination, funding and disease burden, grants should either focus more on investing in long-term use�…. Various additional assessments on this topic are being capacity building or demonstrate partner contributions to capacity-building. considered by the Global Fund. An Options Paper on this topic is 11. The Global Fund Secretariat should work with internationally-mandated being developed for consideration by the Board. technical partners, country counterparts, and in-country civil society and  Secretariat will support strategic investments in health systems as private sector partners to strengthen country surveillance and M&E part of proposals to scale up the fight against the three diseases, systems, taking into account the needs of PBF. In particular and in active with priority given to strengthening service delivery platforms and collaboration with country-level partners, the Secretariat should in-country M&E systems. systematically identify and address additional requirements for achieving  It will work with the GAVI Alliance and the World Bank, with adequate oversight at the sub-recipient level. facilitation of WHO, to align funding for HSS and to roll out a shared investment strategy for such strengthening in 2010. 4. Equity The Global Fund has 12. The Global Fund and its partners should ensure that in both applications  The Gender Equality Strategy and Plan of Action 2009—2012 has modeled equity in its for funding and country health information systems there is explicit been developed and is being implemented. Gender expertise in guiding principles and inclusion of indicators for service quality and equity issues related to the Technical Review Panel is being strengthened, development organizational gender, sexual minorities, urban-rural, wealth, and education in order to partner agencies with gender technical assistance capabilities will structure. However, more effectively monitor the access to services among vulnerable be mapped, and gender issues will be included in Secretariat much more needs to populations. partnership agreements. be done to reflect 13. The Global Fund should integrate and highlight equity issues related to  Working with development partner agencies, countries will be those efforts in grant gender, sexual minorities, urban-rural, wealth, and education disparities in provided guidance on gender- and equity-related indicators. M&E performance. the development of its partnership strategies. Toolkits will include such indicators and systems strengthened to 14. The Global Fund Secretariat should collaborate closely with technical monitor and report. partners and country stakeholders to develop program strategies and build  Secretariat is also developing an implementation plan on Sexual the in-country capacities required to better identify and reach vulnerable Orientation and Gender Identities (SOGI). populations. 5. Performance-Based Funding (PBF) The PBF system has 15. The Global Fund should urgently seek a more coordinated approach and PBF and M&E contributed to a focus the more systematic investment of partners to strengthen country health  PBF is still the cornerstone of Global Fund’s management of its on results. However, it information systems, which are needed as the basis for monitoring grant portfolio. In light of tremendous data quality issues, there will continues to face overall progress, enabling PBF, and conducting ongoing evaluations. be greater investments in M&E to benefit both the PBF system considerable 16. The Global Fund should comprehensively examine its PBF objectives, and the overall focus on results. limitations at the policies, procedures, guidelines, and current functioning while reviewing  New grant performance rating and disbursement decision-making country and Appendix G 50 Findings Recommendations Program Response Secretariat levels. the PBF experiences of other partners, most notably GAVI. methodology has been rolled out. 17. The Global Fund Secretariat should revise quality assurance guidelines to  A Data Quality Task Force has been established to coordinate distinguish approaches among settings where existing data systems initiatives such as Data Quality Audits and annual onsite are or are not capable of providing the outcome-level information required verification of grant data by LFAs. for PBF. As a part of this exercise, the Global Fund should review the  There will be greater alignment of Global Fund M&E requirements implications of weak data systems on the guidelines for the operations of with the national Health Management Information Systems of the Technical Review Panel and the LFAs. countries to reduce the burden of reporting. 18. The Global Fund should reaffirm its aspirations to PBF principles, while A new Global Fund Evaluation Agenda is under development as a proposing more differentiated approaches to quality assurance that are result of the FYE experience. (see TERG 13th Meeting – section capable of improving performance and accountability monitoring within 7.2) existing capacity constraints in countries. 6. Global and County-Level Partnerships The Global Fund 19. The Global Fund Board should reaffirm its commitment and reconsider its Global Fund Business Model partnership model has approach to institutional partnerships at the global level, clearly  In response to questions about its business model, the Global opened spaces for the articulating its partnership priorities and the specific arrangements and Fund declared that it was—and will remain—a financing entity. participation of a agreements required to achieve its objectives.  It reaffirmed its commitment to the country-based model and broad range of 20. The Global Fund Board should consider what efforts will be required to emphasized the inclusion and engagement of civil society at all stakeholders. This bring about agreed-upon, effective, and enforceable strategic divisions of levels. progress labor between the Global Fund and the other main multilateral  There was stronger commitment to harmonizing Global Fund notwithstanding, organizations involved in international health—in particular with the World support for salary supplementation and aligning Global Fund existing partnerships Bank, UNAIDS, WHO, UNICEF, the Stop TB Partnership, and Roll Back cycles with those of countries. are largely based on Malaria—to fully capacitate the envisioned partnerships with civil society good will and shared Engagement with Development Partners and the private sector. This should include, as a first priority, resolving the impact-level issues that impede the provision of essential technical assistance on a  A Partnership Group has been formed in the Global Fund; the objectives rather than reliable and timely basis. It should also address larger, systemic issues Partnership Strategy developed has been approved by the Board on negotiated important to HSS. (November 2009). commitments or 21. The Global Fund Secretariat should work with partners through the  A framework for strategic division of labor, clarity of roles, and clearly articulated carefully differentiated approaches it seeks in its various areas of work coordination and mechanisms for funding technical assistance has roles and at the global, regional, and country levels – defining in specific terms the been outlined for Global Fund engagement with development responsibilities, and institutional arrangements required to bring to bear the added value of agency partners. do not yet comprise a particular partners at different stages of the grant life cycle.  There has been more outreach by the Global Fund to well-functioning 22. The Global Fund Board, in consultation with the Secretariat, should ensure development partner agencies. This included strengthening of system for the that the structure, function, and size of the Secretariat reflects its relationships with GAVI, the World Bank, and IHP, particularly on delivery of global strategic role in a clearly defined partnership framework, distinguishing HSS. public goods. functions to be fulfilled by partners versus those to be fulfilled by the Global Fund Secretariat Secretariat.  It is being reorganized to be more efficient. Using international 51 Appendix G Findings Recommendations Program Response benchmarks, the work force will be based on an $8.8 million operational budget per full-time employee.  The Secretariat budget has been capped at 10 percent of total expenditures 7. Country Coordinating Mechanism (CCM) As the core 23. The Global Fund should place greater emphasis on the CCM function  Secretariat will work with CCMs to ensure transparent governance partnership than on the CCM entity. processes and improve their overall effectiveness. Functions of mechanism at the 24. In the majority of cases where the CCMs are not providing ongoing CCMs (including grant oversight) and adherence to minimum country level, CCMs oversight and monitoring functions, the Global Fund should strengthen eligibility requirements will be reviewed. have been successful CCM capacities and/or focus their efforts more exclusively in the domain  The Global Fund is signatory to the Paris and Accra Accords and in mobilizing partners of proposal development and submission. will abide by the guiding principles of harmonization and for submission of 25. The Global Fund should work with partners and country counterparts to alignment. CCMs would be encouraged to be more in line with proposals. However, incorporate the CCM functions into other CCM-like mechanisms within other national coordinating bodies. in the countries existing country-level architecture for coordination and planning in the studied, their grant  Additionally, the Global Fund will now harmonize its approach to health and social sectors, particularly where the Global Fund is funding oversight, monitoring, salary support and compensation and align its grant cycle with national strategies and/or seeking to support HSS. In doing so, the Global and technical country planning and budgeting cycles. Fund should be diligent in ensuring that the principles of transparency and assistance inclusion— in particular with respect to CSO and private-sector in-country  The roles and functions the CCM mechanism will be reassessed mobilization roles partners—are maintained. (by means of direct surveys, comprehensive case study reports, remain unclear and monitoring of membership and funding patterns, adherence to 26. As an essential measure to assure functional partnerships at the country substantially eligibility requirements, etc.) toward improving their effectiveness. level, the Global Fund Board should designate in-country representation unexecuted. The through explicit institutional partnership arrangements with international CCMs’ future role in partners or—as a last resort—through the direct placement of Global Fund these areas and in staff representatives. promoting country ownership is in need 27. The Global Fund and its partners should take steps to increase the of review. inclusion of in-country CSO and private sector partners in country program efforts. The Global Fund, in particular, should: a. Work with country counterparts and international partners to share effective models for increased participation and strengthening of CSO and private sector efforts across development actors and between countries. b. Continue to advocate with host governments for increased CSO and private sector participation in the CCM function. Appendix G 52 Findings Recommendations Program Response 8. Risk Management The lack of a robust 28. The Global Fund should urgently complete its development of a risk  A Risk Management and Accountability Framework has already risk management management framework, beginning with the development of a risk been rolled out. strategy during its first register within the Secretariat that makes risk management activities  This includes a risk policy, an accountability system with detailed five years of operation integral components of strategic and corporate planning, operations, and roles and responsibilities across the organization, and a code of has lessened the decision making. conduct. Global Fund’s 29. The Global Fund Secretariat should utilize the parameters associated with  A corporate risk register will be maintained and updated every six organizational risk of poor grant performance--financial, organizational, operational, and months. efficiencies and political—to determine how resources should be mobilized in support of weakened certain performance, either by the Secretariat or by in-country partners.  A country risk model will be implemented to reduce fraud and conditions for the corruption. Clearer policy and guidelines are being provided to effectiveness of its client countries. investment model.  The role of the Office of the Inspector General (OIG) has been The recent work to expanded to include independent assessments and assurance develop a over key risks and controls of Global Fund country portfolio. comprehensive, corporate-wide risk- management strategy is a necessary step for the Global Fund’s future. 9. Governance The governance 30. The Global Fund Board should consider shifting to a more partnership- Strategic Role of the Board processes of the centric approach to governance in order to reposition the Global Fund in  Consistent with its governance function, the Board now focuses on Global Fund have the global health architecture in a way that maximizes the leverage of its core strategic issues for the Global Fund. developed slowly and financing to effect major efficiencies in the international system of  It has relegated more decision-making authority (especially when less strategically than development assistance for health—specifically focused on AIDS, operational in nature) to Board committees and the Secretariat. required to guide its tuberculosis, and malaria, but mindful of the broader national health intended partnership structures and systems that will require strengthening to achieve its  Note: A subcommittee has been formed by the Board (see Global model. objectives. Such an approach would involve the Board reexamining the Fund/B21/4 Report of the Policy and Strategy Committee) to roles and responsibilities presently carried out by the Secretariat, respond to Global Fund management responses. considering which of those roles could and should be played by partners. 31. The Global Fund Board should take steps to reconcile its founding principles with the unrealized assumptions required for their actualization. Specifically: a. Improved country-owned coordination, with the full participation 53 Appendix G Findings Recommendations Program Response and inclusion of stakeholders, is required to ensure that the partnership model functions effectively at the country level. b. Strengthened country information capacities are required to support PBF. c. Explicit financing mechanisms are required to fully engage the international technical partners. 32. The Global Fund Board should support the development of a more coherent vision and mission statement that sets a hierarchy and contextual boundaries for the application of the Global Fund Guiding Principles, focuses on issues—especially partnership and M&E—that have not yet received sufficient attention and defines more precisely the current status and future orientations of the Global Fund business model. 33. The Global Fund Board should provide clear guidance to the Global Fund Secretariat with respect to strengthening or limiting its roles relative to those of its partners in the areas of financing, policy, and development assistance in order to better situate and differentiate the Global Fund in the global development architecture. Appendix H 54 Appendix H. Global Fund and World Bank Assistance to the Six Countries Visited Table H-1. Burkina Faso: Global Fund Grants, Commitments and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved - 2 1 - 1 2 1 2 2 - 11 HIV/AIDS 1 1 1 3 Tuberculosis 1 1 2 4 Malaria 1 1 2 4 Grant amounts (US$ millions) - 15.6 5.5 - 5.4 66.8 25.4 54.1 14.0 - 186.7 HIV/AIDS 8.8 5.4 55.4 69.5 Tuberculosis 5.5 11.4 14.0 30.9 Malaria 6.8 25.4 54.1 86.3 Disbursements (US$ millions) - 1.3 6.2 8.7 6.1 9.3 25.4 29.6 62.2 12.4 161.3 HIV/AIDS 0.7 2.0 3.2 3.7 6.1 13.2 12.4 13.4 4.8 59.5 Tuberculosis 1.9 1.3 2.4 3.2 5.0 2.4 5.0 3.0 24.2 Malaria 0.6 2.3 4.2 7.3 14.8 43.8 4.6 77.6 a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-2. Burkina Faso: World Bank Projects, Commitments and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects - - 1 - - 0a 1 - 0a - 1 0a 3 approved Commitments (US$ millions) - - 22.0 - - 5.0 47.7 15.0 2.7 36.0 128.4 Of which: Health system performance 3.1 13.8 2.6 19.5 HIV/AIDS 6.4 3.4 13.8 18.0 41.6 Malaria 6.7 5.0 11.6 Disbursements (US$ millions) 13.2 5.9 4.4 4.6 7.8 7.4 5.7 4.8 15.4 12.6 20.9 5.3 108.0 Of which: Health system performance 2.6 1.1 0.7 0.6 1.1 1.0 0.8 1.1 4.5 3.7 6.0 1.5 24.7 HIV/AIDS 1.8 0.8 0.9 1.3 2.3 2.1 1.6 1.4 4.5 3.7 6.0 1.5 27.9 Malaria 0.4 2.2 1.8 2.9 0.7 8.0 a. Supplemental financing for a previously approved project. 55 Appendix H Table H-3. Tanzania: Global Fund Grants, Commitments, and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved 1 1 1 5 - 1 1 3 - 2 15 HIV/AIDS 1 4 2 7 HIV/tuberculosis 1 1 Tuberculosis 1 1 Malaria 1 1 1 1 1 5 Health systems strengthening 1 1 Grant amounts (US$ millions) 78.1 4.6 66.8 340.7 - 24.2 16.3 221.6 - 135.3 887.5 HIV/AIDS 4.6 265.6 121.1 391.4 HIV/tuberculosis 66.8 66.8 Tuberculosis 24.2 24.2 Malaria 78.1 75.1 16.3 100.4 60.7 330.6 Health systems strengthening 74.6 74.6 Disbursements (US$ millions) - 2.3 12.2 68.2 60.2 72.2 169.1 106.5 141.4 51.7 683.6 HIV/AIDS 1.8 43.8 27.2 28.4 84.5 47.9 79.0 0.4 313.1 HIV/tuberculosis 7.1 2.6 10.8 14.1 20.3 12.0 66.8 Tuberculosis 7.7 7.5 15.2 Malaria 0.5 5.1 21.8 22.2 22.0 56.9 58.6 50.4 35.7 273.1 Health systems strengthening 15.6 15.6 a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-4. Tanzania: World Bank Projects, Commitments, and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects 1 - - - 2 - - - 0 - 1 - 4 approved Commitments (US$ millions) 22.0 - - - 135.0 - - - 60.0 - 40.0 - 257.0 Of which: Health system performance 6.4 18.9 19.8 11.6 56.6 HIV/AIDS 6.4 28.0 34.4 Malaria 9.1 19.8 5.6 34.5 Disbursements (US$ millions) - 0.9 4.3 11.2 6.9 40.7 22.7 31.2 41.0 33.0 49.1 18.7 259.7 Of which: Health system performance 0.2 1.2 3.2 1.2 10.8 3.4 4.4 6.0 4.9 11.8 5.4 52.7 HIV/AIDS 0.2 1.2 3.2 2.1 1.4 4.4 6.4 8.1 6.4 3.4 36.9 Malaria 0.2 10.8 3.4 4.4 6.0 2.4 5.7 2.6 35.6 Appendix H 56 Table H-5. Cambodia: Global Fund Grants, Commitments, and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved - 4 - 2 3 1 1 2 2 1 16 HIV/AIDS 2 1 1 1 1 6 Tuberculosis 1 1 1 3 Malaria 1 1 1 1 1 5 HSS 1 1 2 Grant amounts (US$ millions) - 45.4 - 46.4 45.7 22.9 22.5 18.519.2 67.9 53.4 323.4 HIV/AIDS 29.5 36.5 33.2 22.5 53.4 175.1 Tuberculosis 6.2 9.0 8.3 23.5 Malaria 9.7 9.9 22.9 10.9 56.1 109.6 HSS 3.5 11.7 15.2 Disbursements (US$ millions) - 6.5 5.5 18.8 22.2 21.1 37.9 46.4 61.2 22.8 242.4 HIV/AIDS 4.0 4.5 12.4 15.9 13.3 24.0 28.2 15.2 18.6 136.0 Tuberculosis 0.6 0.5 1.3 2.3 3.0 2.0 6.5 4.5 1.2 21.8 Malaria 2.0 0.5 5.2 3.1 4.5 10.6 11.3 35.4 3.0 75.5 HSS 0.8 0.3 1.3 0.5 6.2 9.0 a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-6. Cambodia: World Bank Projects, Commitments, and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects - - - 1 - - - - 1 - - - 2 approved Commitments (US$ millions) - - - 27.0 - - - - 30.0 - - - 57.0 Of which: Health system performance 5.9 9.9 15.8 Tuberculosis 6.2 6.2 Disbursements (US$ millions) 5.3 6.4 6.4 2.8 4.0 1.9 3.7 3.1 6.5 6.5 6.6 8.8 62.0 Of which: Health system performance 2.1 2.6 2.6 1.1 0.9 0.4 0.8 0.7 1.4 1.6 1.9 2.6 18.7 HIV/AIDS 2.1 2.6 2.6 1.1 8.4 Tuberculosis 0.9 0.4 0.8 0.7 1.5 1.1 0.6 0.6 6.8 57 Appendix H Table H-7. Nepal: Global Fund Grants, Commitments, and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved - 2 - 2 - 1 6 - 1 1 13 HIV/AIDS 1 1 3 1 6 Tuberculosis 1 1 1 3 Malaria 1 1 2 4 Grant amounts (US$ millions) - 7.3 - 25.2 - 4.6 31.9 - 22.2 2.2 93.4 HIV/AIDS 4.8 4.6 19.2 2.2 30.8 Tuberculosis 7.2 3.6 22.2 33.0 Malaria 2.5 18.0 9.1 29.6 Disbursements (US$ millions) - 0.2 0.8 0.6 5.5 9.2 12.2 9.8 20.5 4.5 63.1 HIV/AIDS 0.1 0.3 0.6 3.0 3.2 5.9 5.1 3.4 1.7 23.2 Tuberculosis 1.4 1.5 1.8 4.2 7.1 2.7 18.7 Malaria 0.1 0.5 1.0 4.5 4.5 0.6 9.9 21.2 a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-8. Nepal: World Bank Projects, Commitments, and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects - - - - - 1 - - 0a - 1 - 2 approved Commitments (US$ millions) - - - - - 50.0 - - 50.0 - 129.2 - 229.2 Of which: Health system performance 16.5 16.5 25.8 58.8 HIV/AIDS 19.4 19.4 Disbursements (US$ 6.6 5.8 - - - 5.6 11.2 13.8 14.0 20.1 24.8 32.0 133.8 millions) Of which: Health system performance 1.1 1.0 1.8 3.7 4.5 4.6 6.6 8.2 7.7 39.3 HIV/AIDS 3.3 3.3 a. Supplemental financing for a previously approved project. Appendix H 58 Table H-9. Brazil: Global Fund Grants, Commitments, and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved - - - - 2 - - 2 - - 4 HIV/AIDS - Tuberculosis 2 2 Malaria 2 2 Grant amounts (US$ millions) 23.0 - - 24.1 - - 47.1 HIV/AIDS - Tuberculosis 23.0 23.0 Malaria 24.1 24.1 Disbursements (US$ millions) 2.4 6.8 10.9 8.5 9.5 38.1 HIV/AIDS - Tuberculosis 2.4 6.8 6.1 3.0 1.8 -20.0 Malaria 4.9 5.5 7.6 18.0 a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-10. Brazil: World Bank Projects, Commitments, and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects - - 1 2 1 - - - 2 2 1 2 11 approved Commitments (US$ millions) - - 68.0 130.0 100.0 - - - 107.7 365.0 67.0 210.0 1,047.7 Of which: Health system performance 9.5 9.9 13.0 22.4 251.9 24.1 150.0 480.9 HIV/AIDS 100.0 19.4 119.4 Disbursements (US$ 74.0 86.3 114.2 58.5 57.2 17.4 88.6 66.2 49.0 19.8 31.0 33.1 695.1 millions) Of which: Health system performance 31.0 41.1 46.2 24.7 19.6 2.4 7.8 6.1 4.0 3.9 6.6 6.0 199.2 HIV/AIDS 9.4 10.4 14.1 4.8 5.0 3.1 40.5 28.8 22.6 138.8 59 Appendix H Table H-11. Russian Federation: Global Fund Grants, Commitments, and Disbursements, by Disease and by Calendar Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 a Total Number of grants approved - - 3 2 1 - - - - 6 HIV/AIDS 1 1 1 3 Tuberculosis 2 1 3 Malaria - Grant amounts (US$ millions) - - 129.2 224.7 13.8 - - - - - 367.7 HIV/AIDS 111.5 136.5 13.8 261.9 Tuberculosis 17.7 88.2 105.8 Malaria - Disbursements (US$ millions) - - 12.7 29.2 57.4 81.5 75.4 61.5 34.3 9.5 361.4 HIV/AIDS 10.9 22.2 41.9 49.5 55.0 41.2 29.9 8.3 258.7 Tuberculosis 1.8 7.1 15.4 32.0 20.5 20.3 4.4 1.2 102.7 Malaria - a. Through June 30, 2011. Data downloaded from the Global Fund Web site on September 5, 2011. Table H-12. Russian Federation: World Bank Projects, Commitments, and Disbursements, by Fiscal Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Total Number of HNP projects 2 2 approved Commitments (US$ millions) - - - 180.0 - - - - - - - - 180.0 Of which: Health system performance 30.9 30.9 HIV/AIDS 43.5 43.5 Tuberculosis 43.5 43.5 Disbursements (US$ 24.0 34.0 14.4 3.7 3.3 1.2 16.5 43.7 41.8 32.6 - - 215.1 millions) Of which: Health system performance 12.3 20.3 4.7 0.8 0.7 0.2 3.0 7.6 7.2 6.0 62.9 HIV/AIDS 0.4 0.2 3.7 10.4 10.0 7.3 32.0 Tuberculosis 0.4 0.2 3.7 10.4 10.0 7.3 32.0 Appendix I 60 Appendix I. Major Findings from the Six Country Visits Topic Burkina Faso Tanzania 1. Additionality and Donor governments have decreased their funding for HIV/AIDS in Burkina Tanzania is heavily dependent on donors for the fight against the three sustainability Faso (a) because they are now contributing to the Global Fund and (b) in diseases. By one estimate, it will not be self-sufficient in the fight against the response to past scaling up of Global Fund support for Burkina Faso. At the three diseases until 2034. time of IEG’s visit In May 2010, the Global Fund was the only financier of Given the high level of dependence on external assistance to fight the three ARV therapy and drugs to prevent mother-to-child transmission for diseases, most Global Fund grants are likely to cause the government to HIV/AIDS in Burkina Faso and bore the responsibility for sustaining shift expenditures to other priority development areas. Domestic-funded HIV/AIDS activities there. expenditures for HIV/AIDS have decreased as external aid has increased. The long-term sustainability of Global Fund financing for HIV/AIDS Some commentators felt that the Global Fund was being too liberal toward programming was threatened by a funding gap until the country’s Round 10 Tanzania in approving new grants, contrary to the Global Fund’s policy of proposal was approved by the Global Fund Board in December 2010. At the taking into consideration the speed of implementation of previous grants time of IEG’s visit in May 2010, Round 6 financing was terminating at the when considering new grant requests. This has detracted from incentives end of 2011, and Burkina Faso had failed to secure additional Global Fund for effective grant implementation and sustainability. financing in Rounds 8 and 9, which surprised all stakeholders. As in Burkina Faso, Global Fund resources have been less predictable than Government commitment to health sector funding is generally strong. those of other donors (such as the World Bank), given the uneven pattern of Global Fund support does not appear to have reduced the government’s grant proposals and the unpredictability of grant approvals. own funding for the health sector. Global Fund administrative procedures associated with its performance- based funding processes had also caused short-term gaps in Global Fund financing, which had hindered staff retention. It was hoped that the “new grant architecture� would address this issue for malaria and tuberculosis. 2. Country The CCM now has broad-based participation in decision making compared The national/institutional context in Tanzania has resulted in significant Coordinating to the situation in 2007, at the time of the Study Area 2 Country Program adjustments to the Global Fund guidelines for CCMs, some innovative and Mechanisms (CCMs) Assessment. productive, and others not. There was no consensus on whether Global Fund-supported activities The Tanzania National Coordinating Mechanism (TNCM) – its CCM – “reflect national ownership and respect country-led formulation and oversees the fight against all three diseases and avian flu. Its Executive implementation processes.� Local NGOs felt that the Global Fund’s Committee comprises five government members, four development proposal process allowed them to apply for funding to support their disease- partners, three private sector representatives, and seven CSO specific agendas. CBOs also found this approach refreshing, compared to representatives. The World Bank only participates when it chairs one of the their experiences with other donors. Most donors support the two “common two multilateral groups represented on the TNCM. baskets� for the health sector and for HIV/AIDS. That for HIV/AIDS is an The TNCM Secretariat is embedded in the Tanzania Commission for AIDS annual plan organized with all partners to facilitate better use of their (TACAIDS) because the Round 1 Global Fund grants covered mostly financial support, not an actual pooling of funds.. HIV/AIDS. This arrangement has continued, even though it was intended to be provisional, and the scope of the TNCM has been expanded to include tuberculosis, malaria, and avian flu. Continuing this arrangement is not 61 Appendix I Topic Burkina Faso Tanzania institutionally sustainable or advisable. It has given rise to inherent conflicts of interest and shortcomings in administrative support that TACAIDS provides to TNCM. Tanzania has a good record in producing quality grant proposals due to the perceived quality of its participatory preparation process and the substance assured by competent consultants. Commenting on an earlier draft of this report, the Global Fund Secretariat has noted that having TACAIDS act as CCM Secretariat was very helpful in the beginning, especially since TACAIDS is under the Prime Minister’s Office. This helped to strengthen the funding and staffing of the CCM Secretariat. It is now the responsibility of the CCM to review the role of TACAIDS and to propose viable changes if necessary. Partnership and The CCM is now more independent of government than before. The chair is The TNCM has a strong government presence. The Permanent Secretary leadership now an academic, no longer the Ministry of Health. The vice-chairs are an of the Prime Minister’s Office chairs the TNCM. NGO (of PLWA) and WHO. Most TNCM meetings are taken up with administrative and procedural matters, leaving little time for strategic discussions. Commenting on an earlier draft of this report, the Global Fund Secretariat said that the CCM has provided an excellent forum to enhance partnership arrangements among the various country stakeholders and development partner agencies, that have contributed to the effective scale up of the country’s HIV, tuberculosis, and malaria responses over the last three years. Governance and NGOs and CSOs represent almost 50 percent of CCM membership, more An NGO representative is the vice-chair of the TNCM (currently the CSO participation than the Global Fund’s 40 percent requirement. The four main religious Christian Social Services Organization). groups and persons with the diseases are well represented. The TNCM chair has shown a preference for NGOs that are not likely to Members of the CCM are integrally involved in national strategic planning challenge the government on Global Fund business. and program implementation for the three diseases. The TNCM terms of reference do not distinguish advocacy NGOs from service providers. These have different interests in terms of preparing and screening proposals and selecting Principal Recipients and sub-recipients. CCM Secretariat The Global Fund has made $43,000 a year available to the CCM The TNCM Secretariat is funded under the TACAIDS budget and by an funding Secretariat since 2009 – an improvement over what was found during the annual subsidy of $43,000 from the Global Fund. work for Study Area 2 in 2007. This covers most administrative expenses, including a small office space and salaries for three staff, but not proposal preparation costs, preparation of background papers, technical assistance, or grant supervision costs. Appendix I 62 Topic Burkina Faso Tanzania CCM oversight The CCM has not developed a systematic, comprehensive way to provide The Global Fund’s Office of the Inspector General (OIG) report found many practices oversight of Global Fund grants. This is the greatest weakness of the CCM shortcomings in the complex system of Global Fund grant oversight in – and there has been no change since Study Area 2 in 2007. The CCM Tanzania. reviews quarterly reports and carries out very few field visits, mostly in Ouagadougou. Some CCM members questioned whether this was even an appropriate role for the CCM. Subsequent to IEG’s visit in May 2010, the CCM submitted a request to the Global Fund in 2011 for technical assistance to review its structure, governance tools, and procedures, as well as its oversight practices. Principal This process is transparent and fair. Applications are solicited in the For reasons of fiduciary controls, the Ministry of Finance and Economic Recipient and newspapers. The CCM reviews and compares the applications, and then Affairs (MOFEA) is the Principal Recipient for most Global Fund grants, Sub-Recipient selects the winner by voting. although not all grants are placed on-budget, due to discrepancies in selection timetables between the national budget and grant approval. The Ministry of Health (MOH) is the lead sub-recipient for all government-implemented grants. Other funds are channeled through NGO partner organizations. The MOFEA representatives on the TNCM have limited availability for Global Fund activities, which has translated into delays in the flow of funds due to its financial gate-keeping role. Losses of grant funds in Round 3 and critical delays in the release of grants for Round 8 were attributed to this. Tanzania has a cascading system of sub-recipients (up to five layers), which has been complex and rendered transactions costly. Conflicts of No one seems concerned that some Principal Recipients and sub-recipients There are numerous conflicts of interest: interest are members of the CCM during their tenure.  TACAIDS, which houses the TNCM Secretariat, is a sub-recipient of several Global Fund grants; the Secretariat is effectively overseeing itself.  There are voting members on the TNCM who are Principal Recipients and sub-recipients, which violates both the Global Fund guidelines and the TNCM’s own rules.  The Principal Recipients and sub-recipients are selected from among those that have played a role in originating Global Fund grant proposals. The TNCM appears not to have effectively enforced its own rules in relation to conflicts of interest. 63 Appendix I Topic Burkina Faso Tanzania CCM–Principal Only the chair and secretary of the CCM meet regularly with the LFA. Communications between the chair, the Secretariat, and the implementers, Recipient–LFA Neither the CCM at large nor a CCM committee meets with the LFA. on the one hand, and the LFA, on the other, are a very sensitive matter. communication While the chair had expectations of complete openness on the part of the LFA, the LFA viewed its own communications with the Global Fund as a confidential matter. Commenting on an earlier draft of this report, the Global Fund Secretariat said that the Tanzanian CCM has now given the LFA a platform during every CCM meeting to highlight key issues in grant implementation/ management and to provide a second opinion on the Principal Recipient’s progress reports. The LFA has also made regular presentations to the Development Partners’ Group. Harmonization While country disease priorities are represented in the CCM, since CCM Harmonization occurs through donor self-coordination. However, the Bank and alignment membership includes stakeholders from each of the three diseases, the has not been actively engaged due to lack of staff resources required to CCM is still seen as a parallel institution that is not fully integrated with attend the many meetings required by this system. Large donors such as country disease management. USAID and PEPFAR have also preserved their own individual practices and standards, especially on M&E. Donors in Tanzania still resist compliance with the “Three Ones� and the Paris Declaration and giving up their own standards and practices. 3. Country-level It remains the case that country-level partnerships are largely based on Technical assistance is currently provided through retained short-term partnerships good will and shared impact-level objectives rather than on negotiated consultants paid by donors or by embedded resident advisors who serve as commitments or clearly articulated roles among partners. counterparts to key managers in the health sector. This has increased Other donors and the government have negotiated a “common basket� for donor dependence, constitutes a deviation from the Paris Declaration, and the general health sector and a second one for HIV/AIDS. A MOU has been is contrary to building local capacity. signed for each basket. The Global Fund is contributing to the strategies and national programs funded by the basket. However, its contributions are earmarked, not pooled with those of other donors. The IHP+ initiative to coordinate funding between the Bank, GAVI, and the Global Fund is still a concept and not a practical reality in Burkina Faso. International WHO, UNICEF, UNAIDS, and UNDP contribute in-kind technical assistance Strong in-country partnerships have contributed to the effective scale up of organizations for proposal preparation and financing for background papers and other the HIV, tuberculosis, and malaria responses over the last three years. technical work. Partners have provided critical support to capacity building and technical assistance, including proposal development. The key partners have included GTZ, Italian Cooperation, UNAIDS, United States (USAID, PEPFAR, Centers for Disease Control, and the President’s Malaria Initiative), WHO, and the World Bank. The Development Partners’ Groups Appendix I 64 Topic Burkina Faso Tanzania for Health and AIDS have been effective forums for discussions and joint agreements to implement programs in a coordinated way. Examples include joint procurement of first- and second-line ARVs by the Global Fund and PEPFAR, and joint procurement of bed nets by the Global Fund, the President’s Malaria Initiative, and the World Bank. Bilateral donors These are less involved with the CCM since they view the CCM as an arm While bilateral donors have their individual health assistance programs, of the Global Fund. They are also supporting the “common baskets� for the they coalesce around the donor working groups, resulting in a coherent general health sector and for HIV/AIDS. position with respect to the three diseases. Most contribute to the health basket, the main funding mechanism for the health SWAp. USAID constitutes a separate donor force, because of its size and the combined efforts of USAID and PEPFAR. Civil society Local NGOs felt that the Global Fund’s proposal process allowed them to NGOs appear to operate in a poorly regulated environment. organizations apply for funding to support their disease-specific agendas. CBOs also (CSOs) found the Global Fund’s approach refreshing, compared to working with other donors. Commercial The involvement of the private sector remains extremely limited, the same The private sector has participated in the TNCM mostly as a mobilizer of private sector finding the Study Area 2 Country Partnership Assessment. Global Fund resources for programs to benefit private sector workers rather than moblizers of private sector funds for the wider community of citizens affected by the three diseases. 4. Performance- There has been a real change in perception among Principal Recipients The low quality of data and the lax discipline in its collection have Based based and sub-recipients in Burkina Faso since the Study Area 2 work in 2007. compromised PBF in Tanzania. Timely availability of data has also been an Funding (PBF) Principal Recipients found it difficult to adapt to the Global Fund’s PBF issue. system at first, but now they see it as a useful system. Several grant The recent Global Fund’s OIG audit found that Progress Updates and recipients have now integrated the Global Fund performance-based Disbursement Requests were not being prepared and submitted on time by indicators into their own planning processes and rely on them for their own Principal Recipients (MOFEA) and that their accuracy and completeness decision making and planning. were not verifiable. The absence of major disruptions in disbursements also reduces the effort to ensure that funding is driven by demonstrable performance at the results level. Commenting on an earlier draft of this report, the Global Fund Secretariat said that two major challenges have been late reporting by the Government Principal Recipient (the Ministry of Finance and Economic Affairs) and the absence of a well-functioning Health Management Information System. The Round 8 HIV grant has plans for strengthening the reporting mechanisms and tracking of funds and health products at all levels, improving overall 65 Appendix I Topic Burkina Faso Tanzania data quality, and integrating the parallel systems for Global Fund reporting into the mainstream M&E system. The Round 8 grant is also providing funding for satellite installation at the district level to enhance the quality of data collection and the flow of information. 5. Service delivery, Global Fund support has expanded prevention and treatment services Grant performance has been moderate, with some challenges experienced. prevention, and tremendously for all three diseases in Burkina Faso. The country report The number of people on ARVs has increased from 20,000 in 2002 to treatment statistics for HIV/AIDS, tuberculosis and malaria support this finding. 200,000 today, over 70,000 pregnant women have received PMTCT Global Fund grants have supported innovative ways of working with NGOs (Prevention of Mother to Child Transmission of AIDS), and over 8.5 million and CBOs, in particular with PAMAC (Program to Support Community people have been treated for malaria using ACT. The Round 8 grant for Associations), which is now the Principal Recipient for the Global Fund malaria has financed the distribution of over 18 million insecticide-treated tuberculosis grant. bed nets under the Universal Coverage Campaign. There has also been excellent collaboration with religious groups. Mobile health clinics that focus on HIV counseling and testing have been another innovative service delivery mechanism. 6. Equity This is first of all an urban-rural issue in Burkina Faso. The focus of Global Equity is embedded in Tanzanian culture, and equity concerns have Fund grants on decentralization has noticeably improved access to services translated into a move toward decentralization that gives districts in rural areas. considerable influence in allocating benefits, including health services. The prevention and treatment programs for HIV/AIDS in the Round 10 grant There is no evidence that any disadvantaged or minority group has been will target high-risk groups (sex workers, homosexuals, truck drivers, etc.) discriminated against in access. for the first time. 7. Domestic health Global Fund–supported activities have contributed to the improved delivery The Bank has made a substantial contribution to strengthening health systems of health services, most notably the expanded availability of health services systems through its Health Sector Development Adaptable Lending in rural areas. Program. Many stakeholders expressed the desire for the Global Fund to provide USAID has also made significant contributions to HSS through its more integrated support to the entire health sector, which would be embedded technical assistance approach. considered a more efficient and coordinated way to support the country’s efforts to prevent and fight the three diseases. 8. Risk management The LFA for Burkina Faso is the Swiss Tropical and Public Health Institute Failures of integrity and probity in the use of Global Fund grants are the (Swiss TPH), which has expertise in both public health and finance. A most costly risk to the program’s beneficiaries and reputation. The LFA is Senior Health Specialist base in Basel oversees the work. One staff person aware of these issues and welcomed the recent OIG audit of Tanzania, from Swiss TPH, based in Ouagadougou, works full time, and two local staff which pointed out many irregularities in procurement. The LFA appears to work part time. be diligent and strict about the use of funds, and has singled out fraud and The Global Fund risks being perceived as exclusively responsible for corruption in many government quarters as the main risk, but has faced funding life-saving treatments in poor countries. This has happened in government reluctance to prosecute such acts. Appendix I 66 Topic Burkina Faso Tanzania Burkina Faso in the case of ARVs and drugs to prevent mother-to-child Commenting on an earlier draft of this report, the Global Fund Secretariat transmission. The Global Fund also finances half of the first-line anti-TB said that the LFA has put in place a risk management framework as medicines and all the second-line anti-TB medicines. and procured mandated by the Global Fund. The Global Fund is also working with the 6,678,158 bed nets as part of the Round 8 malaria project. (The CCM and Principal Recipients to ensure that each Principal Recipient has a government finances the other half of first-line anti-TB medicines.) risk management framework in place. The CCM, Principal Recipients, and development partners are also involved in a graft-theft mitigation initiative to proactively find joint solutions. 9. Global Fund Stakeholders in Burkina Faso have not noticed any shift in the Global Fund Some government respondents requested that the Global Fund simplify its governance, from being a finance-only institution to becoming a more conventional procedures, adopt greater timetable flexibility, and give the LFA more of an organizational development agency. They view the Global Fund as a financing-only “enabler� role than one as “inspector.� vision, and strategy mechanism, with all other aspects of support being provided by other development partners. 67 Appendix I Topic Cambodia Nepal 1. Additionality and The Global Fund has not crowded out other donors—other donors have The country visit did not yield the data with which to assess the additionality sustainability shifted resources (notably for HIV/AIDS) before and after Global Fund entry. of Global Fund grants. This has not been as much a crowding effect, as it has been a substitution Highly aid-dependent Nepal faces real and imminent sustainability risks. At effect. At the same time, independent of the Global Fund, some donors the time of the country visit in May 2010, it was uncertain if the HIV/AIDS were “experimenting� with “division of labor� and consolidating their control program would receive another Global Fund grant, and only a programs selectively. For these donors, the Global Fund has allowed fraction of the World Bank HNP/AIDS project ($130 million) is devoted to movement into areas of their comparative advantage and reduced HIV/AIDS. Grant-funded tuberculosis and malaria programs perform much fragmentation in the sector. Overall financing for health has increased better and would not be affected. Tuberculosis and malaria also receive despite the withdrawal by a large financier, the Asian Development Bank, other donor funds (through a pooled basket). from the health sector. Since IEG’s country visit, the Global Fund Board has approved the Key national programs have become highly dependent on the Global Fund, country’s Round 10 proposal for HIV/AIDS in December 2010, thus however, which poses risks for sustainability and may also reduce securing external financial support for HIV/AIDS for the next five years. incentives for these programs to engage in national planning and review processes. Total external funding (MAP, PEPFAR) for HIV/AIDS has leveled off, accompanied by concerns of sustainability. Prevention programs are beginning to suffer the shortfalls, given the moral obligation and priority to address the needs of the already ill. 2. Country There were strong preexisting donor coordination mechanisms— e.g., The CCM in Nepal has 30 members: 10 from the government, 13 from Coordinating Technical Working Group, Health — which are directly linked to the broader NGOs, 3 from the private sector, 2 multilateral organizations, 1 bilateral Mechanisms (CCMs) development agenda and architecture for the country. Members of donor, and 1 member from academia. The World Bank is not a member. Cambodian CCM were initially drawn from Technical Working Group UNAIDS represents all the multilaterals that participate in the CCM, except members, and provided an enabled environment for Global Fund programs for WHO, which has its own seat. to be aligned and harmonized with the National Strategic Action Plan in Health, which enjoys support from the government and other development- partner agencies. Even though the Global Fund did not pool resources in the common basket to implement the Action Plan, it participated in joint review and planning exercises. Recent changes in CCM composition and reduction in members has substantially increased the NGO powerbase and dilution of Ministry of Health influence. This is well received by the NGO community, although there are some concerns with reduced technical and programmatic competency (diminished numbers of Ministry of Health representatives). The World Bank is no longer on the CCM, as seats for multilateral partners have diminished. There is a system of alternates. Partnership & Technical and programmatic leadership was provided by experienced Nepal is a donor-led country. WHO is viewed as the chief technical agency on leadership Ministry of Health members (directors of national control programs for the the CCM. The Ministry of Health exercises leadership only in tuberculosis and three diseases) and their foreign counterparts from WHO, UNAIDS, and malaria (established programs). In HIV/AIDS there are at least four public and Appendix I 68 Topic Cambodia Nepal USAID. Cambodia created its own Technical Review Panel to help generate quasi-public-sector entities charged with some HIV/AIDS responsibilities, but quality proposals for Global Fund grants. who do not collaborate well. The two principals, the National Centre for AIDS and STD Control (NCASC) and the Board for HIV/AIDS programs (a political body created in response to NGO pressure and intended to lead and set policy) have no clear definition of functions. Commenting on an earlier draft of this report, the Global Fund Secretariat said that the HIV/AIDS situation in Nepal has improved since May 2010, although obvious concerns remain. NCASC is now the Principal Recipient for the Round 7 grant and will also be the Principal Recipient for the Round 10, single-stream-of-funding grant. The Global Fund, in collaboration with the CCM, has carefully and thoroughly assessed the capacity of the NCASC to manage the grant successfully, supported by some 21 staff paid out of grant funds. WHO is also providing support through a P5 position, and other external partner agencies are also helping build capacity. National ownership has been strengthened and the sustainability of Global Fund support for HIV ensured through the Round 10 grant. Governance & CSO participation and power sharing among CCM members have NGOs are vocal, largely active in HIV, and the majority (45 percent) on the CSO participation progressed since the FYE. They assert that the CCM structure has, more CCM. There is one NGO Principal Recipient and there are two NGO sub- than any other, allowed them to share policy space in the country’s sub-recipients (all in HIV/AIDS) on the CCM. Sharing of power is unclear. development agenda. The current vice chair is a CSO. UNDP, an important Principal Recipient implementing HIV/AIDS grants, is not a member. CCM Secretariat The Secretariat was professionally staffed at the time of IEG’s visit in April The CCM had no substantial secretariat or staff at the time of IEG’s visit in 2010, initially with funding from GTZ, and then with an annual $44,000 grant May 2010. One CCM Coordinator and one assistant now staff the from the Global Fund. Secretariat (October 2011) in the Ministry of Health and Population.. The Global Fund subsequently approved an expanded funding agreement for the CCM Secretariat for two years starting June 1, 2010 — $117,842 for the first year and $110,092 for the second year. UNAIDS is also providing $10,882 during the same two-year period. The Secretariat now has three staff — the Secretariat Manager, an Administrative Officer, and a Program and Financial Management Oversight Officer. 69 Appendix I Topic Cambodia Nepal CCM oversight Greater focus is placed on grant performance. An Oversight Committee was It actively presides over preparation of grants and the selection of Principal practices created (2010) to which four (three diseases and one in HSS) technical Recipients and sub-recipients, but does not oversee grant implementation. working groups report. Representatives of Principal Recipients, sub- recipients, and sub-sub-recipients may not serve on the Oversight Committee, automatically disqualifying the implementing agencies of the three national disease programs. The implementing agencies are still able to contribute their technical and programmatic expertise by serving on the technical groups that report to this Oversight Committee. The World Bank agreed to serve on this committee. Principal The selection committees have strict criteria and assessment tools to grade The Ministry of Health was initially the Principal Recipient for the Round 2 Recipient and candidates to be Principal Recipients. Protocols guide every process of the grant for HIV/AIDS (approved December 2005). When the Global Fund sub-recipient CCM, which was cited by the CCM Global Report of 2008 as having among determined that the Ministry lacked capacity, it formally designated the selection the best governance tools and protocols to guide its work. But the LFA is UNDP as a co-Principal Recipient in 2007, after which UNDP essentially responsible for undertaking the final capacity assessment of nominated took over the project rather than helping to build up the capacity of the Principal Recipients. The CCM nominated an NGO to be a Principal Recipient Ministry of Health to implement it. When the Global Fund approved three for the first time. However, the nominated NGO failed the LFA assessment HIV/AIDS grants in Round 7, it assigned one to UNDP and two others to and was not confirmed by the Global Fund Secretariat. NGOs, thus bypassing the government entirely. NCASC is now (October 2011) the Principal Recipient for the Round 7 grant and will also be the Principal Recipient for the Round 10, single-stream-of-funding grant. The report focuses mostly on the relationship between the Principal Recipient and its sub-recipients, and between the different sub-recipients under the same Principal Recipient. With respect the relationship between the different actors within a Global Fund grant—i.e., between a Principal Recipient and its sub- recipients—this is a nonissue for tuberculosis (a well-established program), which is exclusively and effectively administered through the Ministry of Health and public health facilities throughout the country. Partnership between two Principal Recipients in malaria is good. There is good division of labor between the two Principal Recipients (PSI/NGO and Ministry of Health) playing out their respective comparative advantages. Based on historical practice, PSI distributes bed nets while Ministry of Health undertakes rapid diagnosis and treatment. Conflict of interest There is a formal policy on conflict of interest. The new CCM is restructured No substantive concerns about conflict of interest. to prevent ANY entity associated with a potential Principal Recipient or sub- recipient candidate from sitting on the CCM. Thus many members of the Ministry of Health are disqualified from the CCM. Appendix I 70 Topic Cambodia Nepal CCM-Principal The LFA attends all CCM meetings as an observer. Recipient-LFA communication Harmonization See above. No direct reference in the report, but it may be assumed that there is and alignment reasonable alignment and harmonization in the tuberculosis programs, and somewhat less in the malaria programs. The coordination in HIV/AIDS is more problematic. The relations among the different agencies are complicated, including the top-level National AIDS Council that is supposed to set overall policy and the District AIDS Coordination Committees that are meant to oversee the actions of NGOs and community-based organizations. 3. Country-level Global Fund is being drawn willingly into existing coordination mechanisms and The report focuses on HIV/AIDS where there is absence of good working partnerships is interfacing more actively with the government and donor partners. A clear partnerships between government (Ministry of Health) and the Principal connection to national strategies and action plans is also being forged. Absence Recipients. The Ministry of Health has been unable to develop and of a physical on-the-ground presence hinders the Global Fund’s collaborative implement clear and effective policies, which has affected Ministry of Health efforts to some extent, but the Fund Portfolio Manager (FPM) has consistently collaboration with its Principal Recipients, and particularly the NGOs that participated in the yearly Joint Ministry of Health–development partner agency depend on grant support. review and planning exercises. As a new actor on the development scene, the Global Fund will need time to forge enduring relationships with the intertwined stakeholder community. International WHO, UNAIDS, USAID, Japan, France, DFID, AUSAID, the Japan Donor collaboration has been weak, but is improving. Nepal is currently a pilot organizations/bilat International Cooperation Agency (JICA), and the World Bank interact quite country for both JANS and the Health Systems Funding Platform. A joint eral donors significantly with either the CCM or with the FPM. All these agencies with assessment of the national health strategy was carried out in January 2010, and the exception of the World Bank provide technical assistance (in kind or a Joint Financing Agreement supporting the National Health Support Program, directly) to Global Fund–funded activities. Lack of development-partner 2011–15, was signed by the government and the major donors in August 2010 agency staff time is a major constraint to sitting on the CCM and other (DFID, GAVI, UNFPA, UNICEF, USAID, and the World Bank). Funding for committees of the CCM. WHO and UNAIDS draw significantly from their NGOs that cater to most at-risk groups is now transitioning from DFID/UNDP own budget to support CCM–related work. funding to pooled funding, managed by the World Bank. Civil Society But the use of long-term advisers by some development partner agencies and A distinction may be made between well-established international NGOs Organizations the preferred use of international NGOs over local ones have constrained operating in Nepal for decades and with alternative sources of funding and (CSOs) capacity and institution building. The government has begun to challenge the local NGOs that were formed recently and depend on Global Fund finance relevance and cost effectiveness of these measures. Foreign NGOs and to exist or survive. workers are abundant in the country. The government, accustomed to working The composition of CCM is noteworthy for the large presence of NGOs, but alongside expatriates, hires its own foreign consultants for specific tasks such as only one of them has been a Principal Recipient; two of them are actually writing proposals for Global Fund grants. groupings or umbrella organizations of other NGOs, several of which As in other countries, a distinction should be made between international participate as Sub-Recipients. Two of established international NGOs (SCF 71 Appendix I Topic Cambodia Nepal NGOs and local CBOs, who may be more connected to local communities and PSI) are U.S.-based and are important Principal Recipients, but don’t and more relevant in sustaining services and benefits, but may currently be sit on the CCM. weak in technical and programmatic and managerial skills, which prevents them from being Principal Recipients and sub-recipients. Commercial Their participation is quite minor at the CCM. Although this sector occupies three CCM seats, their actual involvement in private sector Global Fund services is minimal, e.g., as vendor of drugs. Their view is that the Ministry of Health sees them as a rival rather than as a partner. 4. Performance- PBF is working well in Cambodia because the country has had considerable Given the situation (political unrest and capacity problems in HIV), PBF is a Based based experience with it. Results-based financing was first introduced in 1999 by the remote goal. Stringent application of the concept risks termination and Funding (PBF) Asian Development Bank. This entailed the contracting of Preferred Health disruption of services already supported. PBF may be more feasible for Care and maternal and child health service delivery to NGOs and district tuberculosis and malaria but may still require careful specification of what health authorities, based on compensation for results. Subsequently, other “performance� means and should constitute only a marginal share of grant development partner agencies, including the World Bank, have followed with funding. PBF-type schemes. Commenting on an earlier draft of this report, the Global Fund Secretariat PBF processes as applied to Global Fund grants has been varied: imperfect did not agree that implementing PBF in new grants may lead to disruption of but improving as more Principal Recipients and the LFA develop a better services. The application of PBF is challenging in Nepal, but PBF needs to working understanding of one another. The requirement for PBF still favors work in situations where M&E is weak and also provides important the selection of “established� groups, with proven programmatic, technical, incentives for improving M&E. The World Bank, the Global Fund, and other and financial competency, to serve as Principal Recipients. PBF should be external development partners have contributed to significant institutional applied to the entire service delivery chain, from Principal Recipients to capacity building during the last two years, particularly in the National Sub-Sub-Recipients. Centre for AIDS and STD Control, which is now the Principal Recipient for Under the new CCM structure, the Technical Working Groups under the the Round 7 grant and will be for the Round 10 grant. The external Oversight Committee may now monitor and review the work plans of sub-sub- development partners, together with the Ministry of Health and Population, recipients and sub-recipients. Until now this has been the sole responsibility of have recently agreed to make M&E a core element in the HSS grant the Principal Recipients. Overall, the PBF experience of the Global Fund in application for Round 11. Nepal is no different from other countries where Cambodia can be characterized as promising but with challenges. support for HIV control is particularly sensitive, and needs constant support and supervision. 5. Service delivery, There is little doubt that the significant resources marshaled by the Global Based in large part on data available on the Global Fund Web site, the prevention, and Fund in the country have expanded critical services in all three diseases. report posits that the expansion of services could not have happened treatment Cambodia is a success story in AIDS, having reversed the epidemic. without Global Fund grants. The tuberculosis program is the most Among the achievements are 100 percent condom use among sex workers successful and reported having successfully treated 89 percent of cases in 24 provinces and 32,000 people (including 3,000 children) receiving ART. enrolled. Global Fund support for malaria and HIV/AIDS currently emphasizes preventive measures over treatment. There are signs of drug These achievements were the product of good technical and programmatic resistance to tuberculosis and malaria. collaboration among the government, foreign partners, and civil society, and would not have happened without the sustained funding from the Global Global Fund grants for HIV/AIDS have been rated poorly compared to those for tuberculosis and malaria. The short-term need to get results from the Appendix I 72 Topic Cambodia Nepal Fund. grant appears to have trumped the long-term interest in making the Ministry Among the innovations jointly supported by Global Fund and UNAIDS is and the National Center for AIDS and STD Control (NCASC) more analytical work that gives insight into cost projections for 50 years, modeled competent. after Cambodia as a case study. The country also has the best-costed Commenting on an earlier draft of this report, the Global Fund Secretariat National Strategy Action Plan in the world, which is population-based. agreed that the performance of HIV grants is vulnerable. Grants have been rated poorly, mainly due to dysfunctional governance. But the situation has improved since 2010. Short-term needs have not trumped long-term interests. The Global Fund recognizes the need for national development and ownership, and has actively supported the CCM in transferring more and more responsibility to the NCASC. The Global Fund supported the Family Planning Association of Nepal, an important NGO working with most at-risk people, through a difficult phase and despite severe malfunctions, in order to strengthen national capacity. External development partners have joined hands in building capacity in the Procurement Department of the Ministry of Health to take over ARV procurement fully in 2012. 6. Equity Global Fund interventions have generally been equitable and in line with the Nepal suffers from some of the inequities common to poor countries, in government’s Health Sector Strategic Plan and three national disease addition to which, the poorest people live in the most remote and programs. The focus of services has been on poor, rural Cambodians and on inaccessible parts of the country. By expanding access, Global Fund high-risk and marginalized groups (men who have sex with men, intravenous programs have improved equity, especially for tuberculosis, because DOTs drug users, sex workers). Marginalized groups, often stigmatized, are is now available throughout the country. For HIV/AIDS the issue is whether represented on the CCM. Global Fund data also show that women with AIDS limited resources should be targeted only at the highest-risk groups have equal access to ART with men. There is gender parity with respect to (migrant workers, sex workers, and intravenous drug users), or should getting treatment and drugs. A full package of services is targeted at mothers, include others at risk. The larger ethical issue may arise in how resources which includes antenatal care, HIV testing and counseling, and ARV prophylaxis are allocated between prevention and treatment in the HIV/AIDS program. to prevent mother-to-child transmission. Interventions targeted at the entertainment industry primarily benefit women. 7. Domestic health The Global Fund has allowed for NGOs being an essential part of the The three national programs have very different capacities at the point of systems Cambodian health system, where they play an indispensable role serving delivery and operate quite independently of one another. The strong poor rural populations. Global Fund– supported activities, problematic in the tuberculosis program operates exclusively through the Ministry of Health, beginning, have given way to greater understanding and commitment by and its public facilities have offered nationwide access to DOTs since 2001. Global Fund and development-partner agencies to work in harmonization Prevalence has dropped and transmission is slowing. Malaria, on the and alignment with the country’s health systems. increase as the population migrates to the valley and lowlands, is beginning The recent Health Systems Funding Platform initiative, involving the Global to benefit from improved surveillance, rapid diagnostics, and treatment Fund, the World Bank, and GAVI, facilitated by WHO, creates further offered by the Ministry of Health and bed net distribution and utilization by opportunities for alignment among partners. During an initial consultation the NGO PSI. HIV/AIDS incidence is increasing and treatment is reaching mission in mid-2010, however, the Cambodian government indicated it did only a fraction of the HIV-infected people who need it – due to weak not wish to pool funds from the World Bank and the Global Fund, but governmental leadership and uncoordinated donor behavior. 73 Appendix I Topic Cambodia Nepal welcomed efforts to further align systems for M&E, annual reviews, and fiduciary requirements. Discordant salary scales, particularly egregious in the case of the Global Fund, posed serious problems for sustainability of externally funded activities. Domestic health systems were compromised as talent was drained from the public sector to NGOs and project implementation units working for development-partner agencies. Recently the Priority Operating Costs scheme was introduced by the government, and all development partner agencies, including the Global Fund, have agreed to abide by the scheme and rate set by the government. 8. Risk management As a highly aid-dependent country, Cambodia has sustainability issues in all The principal risk to the Global Fund–supported activities in Nepal is the its development programs. This is also true with Global Fund grants. inability to contain the HIV/AIDS epidemic where prevalence continues to There are examples of the government adopting caution in cost rise, and expanding treatment increases the financial burden. Political containment. For example, in HIV/AIDS, the Ministry of Health has taken instability presents the biggest hurdle, because services in the rural areas over management of all ART programs, in hopes of a better balance are severely affected by such instability. between treatment and prevention. This is a direct result of MAP and Lack of managerial capacity in the government has led to grants going to PEPFAR no longer supporting treatment. UNDP and the NGO sector. It is not clear how the risk of continuing to While this is a good policy on the country’s part, the Global Fund risks bypass the Ministry of Health for HIV/AIDS control should be managed, but becoming the only external agency to fund ART. there is agreement that government capacity and ownership need to be developed. Of immediate concern is Nepal’s difficulty securing HIV grants. It also risks being the primary supporter of tuberculosis and malaria in Failure to get one in Round 10 would have meant the discontinuation of Cambodia and having too many people on ART, which it cannot sustain, ART treatment from previous grants. Last, with expanded use of ART and ACT and other drugs comes the risk of Commenting on an earlier draft of this report, the Global Fund Secretariat drug resistance. Cambodia is at risk of introducing drug-resistant strains of agreed that the effectiveness of the HIV program remains a big concern, but that the three diseases due to illegal peddling of counterfeits and public the situation has improved since IEG’s country visit in May 2010. The Global preference for such drugs because of price. There may be scope for Fund Board approved the country’s Round 10 proposal for HIV/AIDS in expanded support for pharmacovigilance by the Global Fund. December 2010, thus securing external financial support for HIV/AIDS for the next five years. The National Centre for AIDS and STD Control is now the Principal Recipient for the Round 7 and 10 grants. Still, strategic and day-to-day management are weak, and forecasting ARV needs remains challenging due to poor stock management and consumption data surveillance. 9. Global Fund Respondents were satisfied with communications from Geneva in relation to The general perception is that the lack of Global Fund presence constrains governance, Global Fund policies and guidelines, but expressed concerns about the rigid its engagement with other country stakeholders. But there was little offered organizational interpretation of some of the implementation guidelines by the Global Fund in the way of specific suggestions of how to improve the way the Global vision, and strategy Secretariat and the LFA when grants are being executed. Fund operates. Appendix I 74 Topic Brazil Russian Federation 1. Additionality and Additionality: There is no evidence that Global Fund grants have triggered Additionality: There is no indication that Global Fund or World Bank sustainability any reduction of funding by the government of Brazil or by donors. Budgets contributions to the Russian Federation have led to a reduction in that have been set, regardless of grants from the Global Fund. nation’s own contribution. Agreements reached at the beginning of these Principal Recipients in Brazil have been parastatals and foundations, and programs included the understanding that the Global Fund and World Bank as such have not shifted funds as a result of Global Fund grants. They funds would not provoke a decrease in government spending. On the expressed preference for the use of Global Fund grant funds because of contrary, the government increased its national budget for HIV/AIDS from their greater flexibility compared with government funds, which are seen as $20 million to $100 million in 2004 upon conclusion of the Round 3 grant bureaucratic and with high transaction costs. agreement between the Open Health Institute (the Principal Recipient) and the Global Fund. Sustainability: In relative volume, Global Fund grants in Brazil have been small and their absence is unlikely to have any impact on sustainability. The Sustainability: There is substantial concern over the political willingness to government of Brazil seeks funding from the Global Fund for strategic sustain the momentum of some of the programs when the Global Fund reasons, mostly to stay involved with the Global Fund and to fill discrete departs. This appears most pronounced in activities aimed at prevention of gaps in national funding to fight the three diseases. risky behavior and exposure to the AIDS virus. A second example of concern for sustainability is the questionable continuing availability of second- line tuberculosis drugs for drug-resistant disease. The cost of these medications, through the established WHO-administered Green Light Committee mechanism, is far less than that in the open market. As a result of concern over noncompletion of the intended missions and anxiety over inadequate sustainability, program extensions have been proposed and, in one case, established (even though Russia’s per capita income has exceeded the threshold for eligibility for Global Fund participation). 2. Country The CCM consists of the General Assembly (GA) and the Executive There are two CCMs in Russia. The first (and earliest), termed the Coordinating Secretariat (ES). The Assembly is chaired by the head of the CCM, an ex- “Subnational CCM,� is headquartered in Tomsk and is the product of the Mechanisms (CCMs) officio representative from government. The Executive Secretariat consists of NGO, Partners in Health. The nominal leadership has been the head of the the heads of the Principal Recipients and of the government programs for Department of Public Health. However, the real leadership and technical HIV/AIDS, tuberculosis, and malaria, along with CCM members representing contribution have come from the Partners in Health organization. civil society and academia, as selected by the General Assembly. The principal CCM, known as “Big Russia CCM,� is headquartered in The Brazil CCM currently has 26 members, of which 40 percent are from Moscow. The effectiveness of the principal CCM in providing for country civil society, with the remaining members from government, donor partners, ownership appears to be severely compromised by the nonattendance of a and heads of Principal Recipients. The Principal Recipients attend meetings recognized representative from the Ministry of Health and Social but do not vote. There are no private sector representatives in the CCM. Development. The current political commitment is uncertain or is focused in The number of donor partners in the CCM is limited as well. Neither other directions. UNAIDS/Brazil nor the World Bank are members of the CCM. The lack of effective linkage to that Ministry has led to a substantial The tuberculosis grant led to the formation of 11 Urban Committees measure of cynicism concerning its usefulness in practice. These views consisting of local CSOs concerned with tuberculosis. The committees were particularly pronounced among recipient NGOs who see a implement the social engineering parts of the project and hold service pronounced adversarial relationship with them. CSOs and NGOs are providers accountable. They have gradually evolved to be very like regional accepted as full partners. However, the principal CCM is a weak forum for 75 Appendix I Topic Brazil Russian Federation CCMs, inasmuch as they are based in cities spread out in several of the meeting and exchanging proposals and observations, not a true governing state governments of the Brazilian federation. body. There seem to be no private sector representatives in the CCMs. Power sharing among members, especially with NGOs, is apparent. However, the CCM by-laws (Regimento Interno) stipulate that the lead government representative — the Secretary for Health Surveillance of the Ministry of Health — shall remain as chair of the CCM General Assembly in perpetuity. This is inconsistent with the intent of Global Fund policies according to paragraph 8, 10 of the CCM guidelines. However, the same guidelines also state that the Global Fund respects local traditions and customs and does not intend to impose/prescribe the composition of the CCM in a uniform manner across all countries. The CCM has been very vigilant with regard to monitoring conflicts of interest among its members. 3. Country-level CSOs actively participate in the CCM. There is little need to provide Both initiative and momentum of health-related activities in the Russian partnerships capacity building assistance to the civil society sector in Brazilian society. Federation, funded by the Global Fund and the World Bank, have been very Moreover, the appointment of a representative of civil society as the vice- much a product of the energies of a series of NGOs. Many of these were chair of the CCM is also an indication of full participation of this sector. present and active before the Global Fund was initiated. As a result, some The lack of involvement of the commercial private sector was explained by of the resulting programs and activities are concentrated in specific regions the CCM leadership in terms of its failure to come forward in response to — the legacies of prior relationships. Further, some of the long-standing the requests for proposals advertised in the media for each Global Fund regional relationships are strong and established but proceed without clear Round. This was despite the fact that most Principal Recipients are from the relationship to the federal ministry. However, in many cases, the longevity parastatal (foundations) sector, which is strictly nongovernmental. The of their participation has resulted in numerous, strong associations and recent initiative of the Global Fund to familiarize the Brazilian corporate professional partnerships. sector with its operations in Brazil is seen as a possible shift in regard to Cooperation has proceeded best, perhaps, in the programs for tuberculosis. private sector participation. Here, the leadership and personalities representing WHO and the World The drive to include donor partners does not seem to have been as Bank appeared to have been particularly important in shaping effective, proactive in view of the limited number of donors that are members of the cooperative programs and in communicating with the federal ministries. CCM, including those active in HIV/AIDS, such as UNAIDS and the World Bank. Many respondents felt that an invitation to the World Bank to join the CCM would be unlikely, given the general attitude of the government toward involvement of donors in matters seen essentially as of national interest. 4. Performance- The current LFA has found that Principal Recipients are generally not well Both the concept and the details of PBF appear to be well established and Based Funding equipped to provide evidence of grant performance. Data providing this well received in Russia. It has been suggested that an important element in (PBF) evidence is often unavailable, inconsistent, or outdated. It is also difficult to the success of this instrument in practice had been the contribution of attribute grant performance to the inputs secured by the grant, especially information from the Central Research Institute for Health — the research the one for tuberculosis, since these are intermediate products and not at and epidemiology institute for health within the Ministry of Health and Social Appendix I 76 Topic Brazil Russian Federation the delivery end in the service delivery chain. In addition, while all Principal Development, which is responsible for monitoring and measurement. The Recipients have M&E teams, they are challenged to monitor performance work of that institute provides some of the basis for establishing appropriate with data from government databases. The current LFA has therefore taken monitorable indicators and their measurement. it upon itself to systematically instruct these teams on creating recorded The LFA, KPMG, appears very satisfied with the PBF process and the trails that allow the LFA to carry out its verification function. details of the reporting process. The LFA in Russia is assisted by a Central Certain members of the CCM saw PBF as “inappropriate to local Coordination Team in San Francisco, which includes health professionals. circumstances.� The multiple data systems associated with the multilayered Further, all of the KPMG LFA groups convene once each year with the government health systems are not consistent and do not lend themselves to Global Fund to review the process generally. assessing the performance of grants that are small links in a long service chain. 5. Service delivery, Global Fund grants to Brazil provide small inputs for existing health service The Global Fund and World Bank monies have effectively “catalyzed� and prevention, and delivery outlets under the Integrated Health Service (SUS). The tuberculosis leveraged substantial additional spending by the Russian Federation treatment grant to Brazil is a case in point of adjusting service delivery to the local government. The result of the combined financial support has been context and circumstances. It is hard to conclude that these improvements enhanced availability of diagnostic laboratory equipment and pharmacologic would not be introduced in the absence of the Global Fund grants. agents for treatment of disease. In addition, World Bank funds have The Principal Recipients of the tuberculosis grants are not directly involved provided important support for technical assistance and capacity building. in service delivery per se. Achieving their end results depends on the Tuberculosis in particular has benefitted from these programs in both effectiveness of intermediate structures, which combine federal, state, and civilian and prison settings. Concentration on the improvement of laboratory municipal levels of governments to make up the Integrated Health System facilities and methods has brought benefit to two-thirds of the clinical (SUS). The planning of tuberculosis activities covered by the Global Fund laboratories and brought about the establishment of a series of new grant is developed with participation of the Metropolitan Tuberculosis reference laboratories. DOTS — the WHO standard of treatment for drug- Committees and cleared by the CCM. All medication for services is sensitive disease — has been instituted and accepted widely, although not provided by the SUS, free of charge. This enhances the effectiveness of universally. The importance of compliance with therapy and uninterrupted Global Fund grants in a complementary way, since the Global Fund grant therapy has not yet been recognized by all physicians. There remain some covers only certain links of the service delivery chain down to the patient. problems of lower success rates in treatment outcomes and a level of primary multidrug-resistant tuberculosis. However, in general, the programs Evidence of innovation by the Global Fund tuberculosis grant is represented have been successful. Tuberculosis mortality has been declining since by the creation of the Metropolitan Committees for Control of Tuberculosis. 2006. Conditions making this possible have included an effective strategy, These committees bring together all relevant stakeholders that help plan, strong leadership, two government orders dealing with treatment standards, monitor, and provide social accountability of tuberculosis services, helping and identified leadership from key individuals representing the Global Fund to mitigate tuberculosis as a neglected disease of the poor and and World Bank programs and responsible for a particularly cooperative marginalized social sectors. division of effort. Innovation in the case of tuberculosis and malaria is related to the The corresponding record for HIV/AIDS has been more complicated, involvement of community-based CSOs, which seek to balance prevention, ultimately because of the cultural and social forces surrounding that disease treatment, and care, thereby assisting in monitoring and ensuring and the principal risk groups. True incidence and prevalence are accountability of service providers. consistently uncertain because of the difficulty of accounting for all cases. The malaria grant proposal was prepared by the Ministry of Health National There has been an adequate supply of antiretroviral drugs for treatment. Malaria Control Program with technical advice from the Malaria Consultative Laboratory facilities for clinical determinations have been established. At the Committee and formulated/formatted by PAHO. Left to its current service same time, putting in place preventive measures targeted at specific and 77 Appendix I Topic Brazil Russian Federation capabilities, the SUS of the 47 malaria-affected municipalities (with 75 important high-risk groups (intravenous drug users, for example) remains a percent of malaria incidence in Brazil) would have eventually covered most challenge. of the region and provided drugs. However, without the Global Fund grant, A great deal of attention has been devoted to tuberculosis among prisoners this would probably have been done with substandard lab work and in certain parts of the Federation. In part, this has reflected a realization that treatment services and minimal monitoring of results. At the same time, discharged and amnestied prisoners, infected with M. tuberculosis, become without the existing local SUS services, the Global Fund grant would not a source of new infection in the wider community. As a result, World Bank achieve its end results, given its complementarity to existing systems. and Global Fund efforts have been concentrated on prison populations in at Moreover, an improved system of testing and case management will be least selected parts of the Federation. There are, in addition, some introduced by the grant, effectively strengthening health service for the outstanding programs of outreach to patients on tuberculosis drug therapy prevention and treatment of malaria. who are unable to travel to central facilities. The record of reaching high-risk and marginalized groups of HIV-vulnerable individuals such as intravenous drug users remains a substantial challenge. Principal Recipients engaged in preventive endeavors remain frustrated over a job only partially accomplished. 6. Equity In the case of tuberculosis, the CCM and the Principal Recipients in Brazil To the extent that HIV/AIDS program activities do not reach a large regard the tuberculosis grant itself as evidence of attention to equity and the segment of marginalized risk groups, this is an imbalance in the provision of inclusion of the poor and marginalized because it is a disease that affects services. This is, indeed, a serious problem yet to be faced by the national mostly these populations. However, within these populations there is no government. Key population segments are left out and prevention is evidence of monitoring for inequities of gender or race. compromised. 7. Domestic health Brazil, has a reasonable level of health system capacity, and health The Global Fund and World Bank programs for tuberculosis have been systems systems generally function, despite many weaknesses. generally (although not universally) successful in shaping the organization There is no evidence of any partnerships at the country level for Bank- and provision of services for tuberculosis. Not all regions are uniformly supported projects to provide technical assistance for either the preparation covered. Successful programs have depended on the strength of individual or implementation of Global Fund grants. Implementing Principal Recipients leaders and have involved appropriate compromises designed to account in Brazil have been selected on the basis of their implementation capacity for clinical traditions, economic issues, and scientific evidence. and are accordingly assessed by the LFA. Given the close donor role of the The Global Fund and the World Bank efforts for HIV/AIDS have been Pan-American Health Organization (PAHO) in regard to the Ministry of generally well accommodated insofar as diagnosis and treatment are Health of Brazil, it has regularly assisted in formulating and formatting grant concerned. Diagnostic laboratory resources and therapeutic drugs have proposals in both tuberculosis and malaria, despite the Ministry’s alleged been made available. However, there remains a reluctance to embrace capacity to do so on its own. seriously the elements necessary for identifying and treating patients from The malaria project in the Amazon, funded by a Global Fund grant, is high-risk groups. expected to have a discernible impact on health system capacity at the local The Global Fund and the World Bank programs for HIV/AIDS and SUS level, as it provides for health management agents to closely monitor tuberculosis in the Russian Federation have been successful in helping to the early diagnoses of malaria cases and prompt treatment by local clinics. shape the domestic health system to meet the challenge of those diseases. The grant intends this protocol to be internalized over its lifetime by the local At the same time, there is a competition for attention between these SUS, ensuring sustainability of health system capacity. infectious diseases and concern for the burden of non-communicable Appendix I 78 Topic Brazil Russian Federation disease. 8. Risk management During the Global Fund evaluation of the LFA system in 2007, the first LFA Discussions with both representatives of the LFA and with implementing was found to be underperforming and the contract was retendered. parties did not reveal problems in financial accounting or financial risks. The current LFA (Deloite Touche Tohmatsu) appears to be diligent and While there were, on occasion, mild complaints of increased complexity in strict about the uses of funds. In one case, the LFA recommended rejection procedures, Principal Recipients appeared very comfortable with the of a disbursement application because the Principal Recipient had shifted oversight exercised by the LFA. funds from one line item in the grant to another. This was also intended to set a precedent/example that Principal Recipients had to respect fund use, as planned. The LFA has recommended special precautions with regard to the use of funds entrusted to NGOs. On request from the Global Fund, the LFA in Brazil has carried out several procurement reviews, especially with regard to purchases of pharmaceuticals. For the LFA, the greater risk in Brazil is not financial, but failure to achieve set objectives, mostly because of the complexity of the Brazilian SUS health system. 9. Global Fund Few respondents in Brazil had a view on the evolution of the Global Fund Both the Global Fund and the World Bank programs for health entered upon governance, from a purely financial entity to more of a development agency. their activities in the Russian Federation in the face of challenge and organizational opposition from the host government. It was the skill and statesmanlike vision, and strategy leadership of the Russian Health Care Foundation, the project manager, and key recipients that achieved agreement and accommodation. There followed a highly productive period of contribution and cooperation. The programs for tuberculosis, while not 100 percent successful, remain productive and well- received. The Global Fund programs for HIV/AIDS in the Federation are currently judged by the Global Fund Board as incomplete, resulting in an initiative by the Board to extend the program for an additional three years. The Board’s concern is uncertainty over the probability of sustaining the momentum of the accomplishments of the program and the willingness of the Russian Federation government to devote budgetary support to the program. There remains an unresolved tension over the proper strategy to adopt for prevention of exposure and consequent infection. There is a competition for attention between the issue of infectious disease and chronic or non-communicable disease. The World Bank leadership has recognized this competition and the importance of finding an appropriate balance. The more narrowly focused Global Fund (by definition) will encounter this tension. 79 Appendix J Appendix J. World Bank Participation at Global Fund Board Meetings, January 2002 to November 2011 Board Meeting Number Board Member Alternate Board Member Focal Point Delegate Delegate BM 1 Not recorded January 2002 BM 2 Mr. Geoffrey Lamb, Mr. James Christopher Mr. Ivar Andersen, Ms. Angelique DePlaa, Mr. Thomas Duvall, Chief April 2002 Director, Resource Lovelace, Health, Nutrition Sr. Operations Officer, Senior Economist, Counsel, Legal- Mobilization Department and Population Resource Mobilization Resource Mobilization Cofinancing and Project Department Department Department Finance BM 3 Not recorded October 2002 BM 4 Ms. Kyung Hee Kim, Mr. Ivar Andersen, January 2003 Senior Manager, Finance Sr. Operations Officer, Resource Mobilization Department BM 5 Mr. Geoffrey Lamb, Ms. Debrework Zewdie, Ms Kyung Hee Kim, Mr. Ivar Andersen, Mr. Keith Jay, Lead Policy June 2003 Vice President, Resource Program Director, Global Senior Manager, Finance Sr. Operations Officer, Analyst, Resource Mobilization and HIV/AIDS Program Resource Mobilization Mobilization Department Cofinancing Department BM 6 Ms. Debrework Zewdie, Ms Kyung Hee Kim, Senior Mr. Ivar Andersen, Senior Mr. Keith Jay, Lead Policy October 2003 Program Director, Global Manager, Finance Operations Officer Analyst, Resource HIV/AIDS Program Resource Mobilization Mobilization Department Department BM 7 Mr. Geoffrey Lamb, Ms Kyung Hee Kim, Senior Ms. Deborah Mr. Keith Jay, Lead Policy March 2004 Vice President, Manager, Finance Schermerhorn, Principal Analyst, Resource Concessional Finance and Financial Officer, Resource Mobilization Department Global Partnerships Mobilization Department BM 8 Ms. Debrework Zewdie, Ms Kyung Hee Kim, Ms. Lesley Wilson, Quality Mr. Keith Jay, Lead Policy June 2004 Program Director, Global Senior Manager, Finance Control Analyst, Analyst, Resource HIV/AIDS Program Multilateral Trustee Mobilization Department Operations BM 9 Ms. Debrework Zewdie, Ms. Kyung Hee Kim, Mr. Keith Jay, Lead Policy Ms. Sophia Drewnowski, November 2004 Program Director, Global Senior Manager, Finance Analyst, Resource Sr. Partnership Specialist, HIV/AIDS Program Mobilization Department Concessional Finance and Global Partnerships Appendix J 80 Board Meeting Number Board Member Alternate Board Member Focal Point Delegate Delegate BM 10 Mr. Geoffrey Lamb, Vice Ms. Debrework Zewdie, Mr. Francisco Javier April 2005 President, Concessional Program Director, Global Vergara, Financial Officer, Finance and Global HIV/AIDS Program Concessional Finance and Partnerships Risk BM 11 Ms. Kyung Hee Kim, Ms. Debrework Zewdie, Mr. Keith Jay, Lead Policy September 2005 Senior Manager, Program Director, Global Analyst, Resource Concessional Finance & HIV/AIDS Program Mobilization Department Global Partnerships BM 12 Ms. Debrework Zewdie, Mr. Keith Jay, Lead Policy December 2005 Program Director, Global Analyst, Resource HIV/AIDS Program Mobilization Department BM 13 Ms. Debrework Zewdie, Mr. Keith Jay, Lead Policy April 2006 Program Director, Global Analyst, Resource HIV/AIDS Program Mobilization Department BM 14 Ms. Debrework Zewdie, Ms. Susan McAdams, Mr. Praveen Desabatla, Mr. Keith Jay, Consultant, November 2006 Director, Global HIV/AIDS Acting Manager, Financial Officer, Multilateral Trustee Program Multilateral Trustee Multilateral Trustee Operations Operations Operations BM 1st Ms. Margaret C. Thalwitz, Special Director, Global Programs February 2007 and Partnerships BM 15 Ms. Debrework Zewdie, Ms. Susan McAdams, Mr. Praveen Desabatla, April 2007 Director, Global HIV/AIDS Acting Manager, Financial Officer, Program Multilateral Trustee Multilateral Trustee Operations Operations BM 16 Ms. Susan McAdams, Ms. Alice Miller, Dr. Olusoji Adeyi, Mr. Suprotik Basu, Public Mr. Johannes Kiess, November 2007 Director, Multilateral Senior Financial Officer, Coordinator, Public Health Health Specialist, Malaria Jr. Professional Officer, Trustee Operations Multilateral Trustee Programs Control Booster Program – Multilateral Trustee Operations Africa Region Operations BM 17 Mr. Phillippe Le Houerou, Mr. Julian Schweitzer, Ms. Susan McAdams, Dr. Olusoji Adeyi, Mr. Praveen Desabatla, April 2008 Vice-President, Director, Health, Nutrition Director, Multilateral Coordinator, Public Health Financial Officer, Concessional Finance and and Population Trusteeship and Innovative Programs Multilateral Trusteeship Global Partnerships Financing and Innovative Financing 81 Appendix J Board Meeting Number Board Member Alternate Board Member Focal Point Delegate Delegate BM 18 (designated), Ms. Susan (designated) Mr. Olusoji Dr. Anne M. Pierre-Louis, November 2008 McAdams, Director, Adeyi, Coordinator, Public Coordinator, Booster Multilateral Trusteeship Health Programs Program for Malaria, and Innovative Financing Control in Africa BM 19 (designated) Ms. Susan (designated) Mr. Armin Mr. Johannes Kiess, May 2009 McAdams, Director, Fidler, Advisor, Policy and Jr. Professional Officer, Multilateral Trusteeship Strategy Multilateral Trusteeship and Innovative Financing and Innovative Financing BM 20 (designated) Ms. Susan (designated) Mr. Mukesh November 2000 McAdams, Director, Chawla, Sector Manager, Multilateral Trusteeship Health, Nutrition and and Innovative Financing Population BM 21 (designated) Ms. Susan (designated) Mr. Armin Mr. David Crush, April 2010 McAdams, Director, Fidler, Advisor, Policy and Sr. Financial Officer, Multilateral Trusteeship Strategy Multilateral Trusteeship and Innovative Financing and Innovative Financing BM 22 (designated) David Wilson, Mr. David Crush, December 2010 Program Director, Global Sr. Financial Officer, HIV/AIDS Program Multilateral Trusteeship and Innovative Financing BM 23 (designated) Ms. Susan (designated) Mr. Armin Ms. Priya Basu, Manager, Ms. Veronique Bishop, Mr. Alexandru Cebotari, May 2011 McAdams, Director, Fidler, Advisor, Policy and Multilateral Trusteeship Sr. Financial Officer, Financial Officer, Multilateral Trusteeship Strategy and Innovative Financing Multilateral Trusteeship Multilateral Trusteeship and Innovative Financing and Innovative Financing and Innovative Financing BM 24 (designated) Ms. September 2011 Veronique Bishop, Sr. Financial Officer, Multilateral Trusteeship and Innovative Financing BM 25 (designated), Mr. Armin (designated) November 2011 Fidler, Advisor, Policy and Ms. Veronique Bishop, Strategy Sr. Financial Officer, Multilateral Trusteeship and Innovative Financing Appendix K 82 Appendix K. World Bank Involvement in Global Health Partnerships and Financial Intermediary Trust Funds World Bank’s Roles in the Program Start Location of DGF Implementing Program date secretariat financing agency Governing bodies Bank participation Global Health Partnerships (Not Supported by Financial Intermediary Funds) Permanent member of Policy and Special Programme of Research, Policy and Coordination Coordination Committee and Development and Research Training in 1972 WHO, Geneva 1998–2011 No Committee / Standing Committee Standing Committee of Human Reproduction (HRP) of Cosponsors Cosponsors Special Programme for Research and Joint Coordinating Board / Member of the Standing 1975 WHO, Geneva 1998–2011 No Training in Tropical Diseases (TDR) Standing Committee Committee Cosponsor member of Programme Joint United Nations Program on HIV/AIDS 1994 Geneva 1998–2011 Yes Programme Coordinating Board Coordinating Board without voting (UNAIDS) rights Global Forum for Health Research 1998 Geneva 1998–2011 No Foundation Council Voting member International AIDS Vaccine Initiative (IAVI) 1996 New York 1998–2010 No Board of Directors None European Observatory on Health Systems 1997 WHO, Brussels 2004–2011 No Steering Committee Voting member and Policies Partners' Forum / Board / Voting member of the Board and Roll Back Malaria (RBM) 1998 Geneva 1999–2011 No Executive Committee Executive Committee Medicines for Malaria Venture (MMV) 1999 Geneva 2000–2011 No Board of Directors None Partners' Forum/ Coordinating Stop Tuberculosis Partnership (Stop TB) 2001 WHO, Geneva 2000–2011 No Voting member of Board Board / Executive Committee Health Metrics Network (HMN) 2005 WHO, Geneva 2009–2011 No Board of Directors Voting member Partnership on Maternal, Newborn and Partnership Forum/ Board / Voting member of Board and 2005 WHO, Geneva 2011 No Child Health (PMNCH) Executive Committee Executive Committee International Ministerial Global Program for Avian Influenza Control Conference on Animal and and Human Pandemic Preparedness and 2006 World Bank Yes Co-chair of the Advisory Board Pandemic Influenza / Advisory Response (GPAI) Board Lewes, East Medicines Transparency Alliance (MeTA) 2008 No Management Board Voting member Sussex, U.K. 83 Appendix K World Bank’s Roles in the Program Start Location of DGF Implementing Program date secretariat financing agency Governing bodies Bank participation Global Health Partnerships Supported by Financial Intermediary Funds WHO, African Programme for Onchocerciasis Joint Action Forum / Committee of Voting member of Forum and 1995 Ouagadougou, 1998-2011 No Control (APOC) Sponsoring Agents Committee Burkina Faso Global Alliance for Vaccines and Alliance Board/ Executive Voting member of Board and 2000 Geneva 2001-2007 Yes Immunization (GAVI) Committee Executive Committee Global Fund to Fight AIDS, Tuberculosis, Non-voting member of Board (as 2002 Geneva No Partnership Forum / Board and Malaria trustee) Other GRPPs Supported by Financial Intermediary Funds Consultative Group on International World Bank & Biennial Funders Forum / CGIAR 1971 1998-2010 No Chair of Fund Council Agricultural Research (CGIAR) FAO, Rome Fund Council Washington, Two official observers on Council Global Environment Facility (GEF) 1991 Yes GEF Assembly / GEF Council DC (as trustee & implementing agency) Least Developed Countries Fund for Two official observers on Council 2001 GEF Yes LDCF-SCCF Council Climate Change (LDCF) (as trustee & implementing agency) Two official observers on Council Special Climate Change Fund (SCCF) 2001 GEF Yes LDCF-SCCF Council (as trustee and IA) Yes, representing multilateral and Global Partnership for Education 2002 World Bank Yes Board of Directors regional development banks Adaptation Fund (AF) 2008 GEF Yes Conference of the Parties / Board None. CIF Partnership Forum / MDB Member of MDB Committee & non- Clean Technology Fund (CTF) 2008 World Bank Yes Committee / CTF Trust Fund voting member of Trust Fund Committee Committee. CIF Partnership Forum / MDB Member of MDB Committee & non- Strategic Climate Fund (SCF) 2008 World Bank Yes Committee / SCF Trust Fund voting member of Trust Fund Committee Committee. Global Agriculture and Food Security Non-voting member (as trustee) & 2010 World Bank Yes Steering Committee Program (GAFSP) observer (as supervising entity) Nagoya Protocol Implementation Fund Two official observers on Council 2011 GEF Yes NPIF Council (NPIF) (as trustee and IA) Appendix L 84 Appendix L. Overview of the Global Environment Facility and the World Bank’s Roles Objectives and Activities 1. The Global Environment Facility (GEF) was founded by the World Bank, the United Nations Development Program (UNDP), and the United Nations Environment Program (UNEP) in 1991 as an independent financial mechanism to assist developing and transition countries in implementing the following five conventions:  Convention on Biological Diversity (CBD)  United Nations Framework Convention on Climate Change (UNFCCC)  Stockholm Convention on Persistent Organic Pollutants  United Nations Convention to Combat Desertification  Montreal Protocol on Substances That Deplete the Ozone Layer.3 2. The GEF provides grants to developing and transition countries to cover the “incremental� or additional costs of activities intended to protect the global environment and to promote environmentally sustainable development. GEF grants support projects in six focal areas: (a) stemming biodiversity loss, (b) reducing the risks of climate change, (c) safeguarding international waters, (d) eliminating persistent organic pollutants, (e) preventing land degradation, and (f) preventing ozone layer depletion. The first two focal areas — biodiversity and climate change — accounted for 68 percent of the 2,400 projects that the GEF supported in over 150 countries since the GEF was founded through June 2009, and 64 percent of the $8.6 billion of project funding (Table L-1). This does not include cofinancing of GEF-supported projects by the World Bank and other donors, estimated to have been between $30 and 40 billion during this same time period. The GEF has also made more than 12,000 small grants available through its Small Grants Program directly to nongovernmental and community organizations, totaling around $500 million. Table L-1. Number of Projects and GEF Funding by Focal Area, 1991–2009 Projects Funding Focal area Number Share US$ millions Share Biodiversity 946 40% 2,792 32% Climate change 659 28% 2,743 32% International waters 172 7% 1,065 12% Persistent organic pollutants 200 8% 358 4% Land degradation 76 3% 339 4% Ozone layer depletion 26 1% 180 2% Multifocal 310 13% 1,114 13% All focal areas 2,389 100% 8,591 100% Source: GEF Evaluation Office, Fourth Overall Performance Study of the GEF, 2010, p. 8. 3. Although the GEF is not formally linked to the Montreal Protocol, it supports the implementation of the Protocol in countries with economies in transition. 85 Appendix L Governance and Management 3. The GEF is governed by an assembly and a council (Figure 1). The GEF Assembly, which meets every three to four years, is attended by high-level government delegations of all 180 GEF member countries. It is responsible for reviewing the GEF’s general policies, operations, and membership, and for considering and approving proposed amendments to the GEF Instrument — the document that established the GEF and sets the rules by which the GEF operates. Figure L-1. The GEF Structure 4. The GEF Council is the main governing body of the GEF. It functions as an independent board of directors, with primary responsibility for developing, adopting, and evaluating GEF programs. Council members represent 32 constituencies (16 from developing countries, 14 from developed countries, and 2 from transition countries), and meet semi- annually for three days and also conduct business virtually. Decisions are generally by consensus. 5. The GEF Secretariat in Washington, DC, reports directly to the GEF Council and Assembly. The Chief Executive Officer and Chairperson of the Council — currently Monique Barbut — heads the Secretariat. The Secretariat coordinates the formulation of projects included in the work programs, oversees their implementation, and ensures that GEF operational strategies and policies are followed. 6. The Scientific and Technical Advisory Panel provides strategic scientific and technical advice to the GEF on its strategies and programs. This consists of six members who are internationally recognized experts in GEF’s key areas of work and are supported by a network of experts. The Panel is also supported by a Secretariat, based in the UNEP regional office in Washington, DC. The Panel reports to each regular meeting of the GEF Council on the status of its activities, and, if requested, to the GEF Assembly. Appendix L 86 7. GEF Agencies are responsible for creating project proposals and for supervising or implementing approved projects. That is, when establishing the GEF, the member countries involved chose to tap the comparative advantages of three founding organizations to implement its projects, rather than construct a new organization to do so. As implementing agencies, the World Bank, UNDP, and UNEP would assist eligible governments and NGOs in developing, implementing, and managing GEF-financed projects. Starting in 1999, an additional seven executing agencies have been added to the roster of GEF agencies, with similar responsibilities: the Asian Development Bank, the African Development Bank, the European Bank for Reconstruction and Development, the Food and Agriculture Organization, the Inter-American Development Bank, the International Fund for Agricultural Development, and the United National Industrial Development Organization.4 8. The GEF provides an administration fee to GEF agencies, equal to about 10 percent of GEF financing, to cover the costs of project preparation and supervision. GEF agencies focus their involvement in GEF projects within their respective comparative advantages. Initially, the comparative advantage of UNEP was viewed as “catalyzing the development of scientific and technical analysis and advancing environmental management in GEF-financed activities,�5 that of UNDP as developing and managing capacity building programs and technical assistance projects; and that of the World Bank as developing and managing investment projects. In the case of integrated projects that include components where the expertise and experience of one GEF agency is lacking or weak, the agency is expected to partner with another agency and establish clear complementary roles so that all aspects of the project will be well managed. 9. Two types of GEF Focal Points play important coordination roles regarding GEF matters at the country level as well as liaising with the GEF Secretariat and implementing agencies, and representing their constituencies on the GEF Council. All GEF member countries have Political Focal Points, while recipient member countries eligible for GEF project assistance also have Operational Focal Points. Political Focal Points are concerned primarily with issues related to GEF governance, including policies and decisions, and with relations between member countries and the GEF Council and Assembly. Operational Focal Points are concerned with the operational aspects of GEF activities, such as endorsing project proposals to affirm that they are consistent with national plans and priorities and facilitating GEF coordination, integration, and consultation at the country level. World Bank’s Roles in the GEF 10. In addition to being one of the three founding partners of the GEF, the World Bank plays three major roles in the GEF: (a) the trustee and administrator of the GEF and related trust funds; (b) one of the three implementing agencies of the GEF; and (c) a range of administrative support services as the host of the GEF Secretariat, including human resources, communications, and legal services. As such, the World Bank serves as the legal entity for the 4. While the participation of the three implementing agencies in the GEF is governed by the GEF Instrument, the participation of the seven executing agencies is governed by MOUs between the GEF and each agency. 5. GEF, Instrument for the Establishment of the Restructured Global Environment Facility, March 2008, Annex D, paragraph 11. 87 Appendix L GEF Secretariat. However, unlike other GRPPs whose secretariats are physically located in the World Bank, the GEF has its own independent governance structure, with the CEO reporting only to the GEF Council. That is, the program managers of other GRPPs located in the Bank report both to their own governing body and to a World Bank line manager, who reports ultimately to the World Bank President and the Bank’s Executive Board. 11. The World Bank also participates in GEF governance through two official observer positions on the GEF Council (as trustee and implementing agency) and in GEF management as the co-chair (along with the CEO) of the quadrennial replenishment process. 12. As the Trustee, the Bank’s duties, as laid out in Annex B of the GEF Instrument, include the following: resource mobilization, managing receipts from donors, investing the liquid assets of the GEF trust fund, entering into financial procedures agreement with other GEF Agencies to facilitate the transfer of funds, preparing financial reports to the Council, and providing for audit functions. The Trustee does not have programmatic or fiduciary responsibility to the GEF for the use of funds transferred to other Agencies. 13. As an implementing agency, the Bank’s comparative advantages are generally seen as a multisectoral financial institution operating on a global scale. The World Bank has strong experience in investment lending focused on policy reform, institution building, and infrastructure development across all six focal areas of the GEF. 14. The World Bank has been the largest lender for the environment to developing and transition countries. It has prepared many projects in which World Bank and GEF finance have been “blended,� thereby softening the overall financial terms to the borrowing country. The World Bank also houses the secretariats of a number of other environmental partnership programs that are financing investments at the country level, including a series of carbon finance programs and the two Climate Investment Funds (the Clean Technology Fund and the Strategic Climate Fund). GEF Financing 15. The GEF follows a quadrennial replenishment model of financing. Every four years, donor nations make pledges to fund the next four years of GEF operations and activities. Donors pledged $9.3 billion and contributed $8.8 billion during the pilot phase and the first four replenishments ending June 30, 2010 (Table L-2). The fifth replenishment of the GEF concluded in May 2010, during which donors made new pledges of $3.5 billion. Including the carryover of resources from previous replenishments and projected investment income, the overall replenishment value is $4.3 billion. The fifth replenishment became effective in March 2011, when donors whose contributions aggregated not less than 60 percent of the total contributions to GEF-5 had formalized their contributions by depositing Instruments of Commitment with the World Bank as Trustee. GEF-5 replenishment is expected to fund four years of GEF operations. 16. The GEF also operates two additional programs — the Least Developed Countries Fund for Climate Change (LDCF) and the Special Climate Change Fund (SCCF) — and Appendix L 88 Table L-2. GEF Replenishments Pilot GEF-1 GEF-2 GEF-3 GEF-4 Total Phase 1994–98 1998–02 2002–07a 2007–10 1990–10 Funding 1990–94 GEF funding pledged by donors 843 2,015 1,983 2,211 2,289 9,341 GEF funding received from donors 843 2,012 1,687 2,095 2,169 8,806 Purchasing power 100% 85% 95% 95% 94% GEF replenishments as share of Official Development Assistance 0.28% 0.67% 0.60% 0.50% 0.38% (ODA) Source: GEF Evaluation Office, Fourth Overall Performance Study of the GEF, 2010, p. 35. a. Generally speaking, replenishment periods have been from July 1 of the beginning year to June 30 of the ending year. However, the third replenishment period ended February 6, 2007, and the fourth began on February 7, 2007. provides secretariat services for a third — the Adaptation Fund.6 The LDCF addresses the needs of the 48 least developed countries whose economic and geophysical characteristics make them especially vulnerable to the impact of global warming and climate change. The SCCF finances activities relating to climate change that are complementary to those funded by the resources allocated to the climate change focal area of the GEF trust fund and to those provided by bilateral and multilateral funding in the areas of (a) adaptation; (b) transfer of technologies; (c) energy, transport, industry, agriculture, forestry, and waste management; and (d) activities to assist developing countries whose economies are highly dependent on income generated from the production, processing, and export or consumption of fossil fuels and associated energy-intensive products in diversifying their economies. 17. The Adaptation Fund was established in 2008 under the United Nations Framework Convention on Climate Change (UNFCCC) to finance climate change adaptation projects and programs in developing countries that are Parties to the Kyoto Protocol. However, its primary financing comes not from traditional official development assistance, but from a 2 percent share of proceeds of the Certified Emission Reductions (CERs) issued by the Clean Development Mechanism (CDM) under the Kyoto Protocol. 18. The GEF is one of the four largest GRPPs in which the World Bank is involved, along with the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Consultative Group on International Agricultural Research (CGIAR), and the Global Alliance for Vaccines and Immunization (GAVI). Disbursements to GEF projects averaged $464 million during 2002–10. The World Bank as implementing agency supervised about 36 percent of these disbursements (Table L-3). 6. The GEF Council also approved a fourth such program in February 2011 — the Nagoya Protocol Implementation Fund — to support the early entry into force and effective implementation of the Nagoya Protocol on Access to Genetic Resources and the Fair and Equitable Sharing of Benefits Arising from their Utilization. Japan has contributed $12.2 million to the NPID trust fund as of June 30, 2011. 89 Appendix L Table L-3. Donor Contributions to and Project Disbursements from GEF Trust Funds, Fiscal Years 2002–10 (US$ millions) 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Donor Contributions GEF 386.3 513.7 1,003.1 734.0 720.2 831.1 787.5 696.0 580.9 6,252.7 LDCF - 8.6 7.8 4.1 12.4 25.1 37.8 29.0 34.0 158.8 SCCF - - - 8.2 23.7 22.1 21.5 25.0 10.5 110.8 Adaptation Fund - - - - - - - 18.4 152.1 170.4 Total 386.3 522.4 1,010.9 746.3 756.2 878.3 846.7 768.3 777.3 6,692.7 Project Disbursements GEF 208.4 390.3 372.6 391.6 508.9 519.5 674.1 541.8 571.3 4,178.5 LDCF - - 3.6 0.7 5.3 1.1 0.2 3.8 12.7 27.4 SCCF - - - - - 1.7 1.7 4.3 14.7 22.3 Adaptation Fund - - - - - - - - 0.8 0.8 Total 208.4 390.3 376.2 392.3 514.2 522.3 676.0 549.9 599.4 4,229.0 Project Disbursements through World Bank as Implementing Agency GEF 143.4 111.7 134.6 147.3 172.2 189.2 229.8 221.4 173.1 1,522.6 LDCF - - - - 0.2 0.1 0.0 0.0 0.1 0.4 SCCF - - - - - - 0.5 0.1 2.7 3.3 Total 143.4 111.7 134.6 147.3 172.4 189.3 230.3 221.4 175.9 1,526.3 Percent of Total 69% 29% 36% 38% 34% 36% 34% 40% 29% 36% Source: World Bank trust fund database. Note: Both the LDCF and SCCF were established under the GEF in November 2001. The LCDF trust fund was set up in 2002 and began disbursing in 2004. The SCCF trust fund was set up in 2004 and began disbursing in 2007. The Adaptation Fund was established under the United Nations Framework Convention for Climate Change in November 2008 and began disbursing in 2010. 19. The GEF has also become a significant financier of other environmental GRPPs. It has provided financial support for three global programs (the Critical Ecosystem Partnership Fund; the Coral Reef Management Program; and the International Assessment of Agricultural Knowledge, Science and Technology for Development) and for six regional programs (the Africa Stockpiles Program, the Nile Basin Initiative, TerrAfrica, the Black Sea-Danube Partnership, the Inter-American Biodiversity Information Network, and the Mesoamerican Biological Corridor), and has pledged up to $50 million for the Global Tiger Initiative. Regional projects and programs are often subregional in scope, with a contiguous geographic dimension to them such as a body of water (like the Aral Sea or Lake Victoria), or a river system (like the Nile or the Mekong). The programs exist to a large extent for the purpose of resolving collective action dilemmas among participating countries regarding the use of the common resource.7 7. IEG, 2007, The Development Potential of Regional Programs: An Evaluation of World Bank Support of Multicountry Operations. Appendix L 90 20. The GEF Instrument stipulated that the GEF will provide “new and additional grant and concessional funding to meet the agreed incremental costs of measures to achieve agreed global environmental benefits.� While the incremental cost principle has remained central to GEF financing, a 2006 evaluation study by the GEF Evaluation Office found much confusion about incremental cost concepts and procedures in practice. Most incremental cost assessment and reporting, as then applied, did not add value to project design, documentation or implementation.8 At the request of the GEF Council, the Secretariat subsequently prepared in 2007 a revised approach for determining incremental costs, based on incremental reasoning, that links incremental cost analysis to results-based management and the GEF project cycle.9 Resource Allocation 21. The GEF introduced a new Resource Allocation Framework (RAF) in 2006 — now called the System for a Transparent Allocation of Resources (STAR). This represents “a system for allocating resources to countries in a transparent and consistent manner based on global environmental priorities and country capacity, policies and practices relevant to successful implementation of GEF projects.� A midterm review of the RAF conducted by the GEF Evaluation Office found that the new system was proving more successful in channeling GEF resources to countries with high global environmental benefits as measured by the GEF Environmental Index, but less so to countries with strong performance as measured by the GEF Performance Index.10 22. The midterm review also found that the RAF, coupled with other operational changes (such as a change in the rules governing the financing of project preparation), affected agency participation. At the time of the review, the World Bank share of GEF commitments had dropped from more than half of GEF resources to 32 percent of the GEF RAF resource utilization in the two focal areas of biodiversity and climate change, while the United Nations Development Program (UNDP) share increased from 28 percent to 43 percent. The role of the seven executing agencies also increased to 17 percent of RAF utilization, compared with 2 percent of all historical resources. These shifts reflected the spreading of small RAF allocations over many countries, which made it more difficult for the World Bank to blend GEF finance with Bank lending, since other environmental funds were now easier to utilize than GEF RAF support. The UNDP has greater ability to provide technical assistance and capacity building supported by local offices and has been more ready to engage in relatively small projects under the RAF (now STAR). 8. GEF Evaluation Office, 2006, Evaluation of Incremental Cost Assessment, GEF Council Document GEF/ME/C.30/2. 9. GEF, 2007, Operational Guidelines for the Application of the Incremental Cost Principle, GEF Council Document GEF/C.31/12. 10. GEF Evaluation Office, 2009, Mid-Term Review of the Resource Allocation Framework, GEF Evaluation Report No. 47. 91 Appendix L Direct Access 23. The GEF Council has recently approved two new implementation modalities to provide countries with more direct access to GEF resources without one of the ten implementing agencies playing an intermediary role. These are is seen as being consistent with the 2005 Paris Declaration principle of country ownership, as well as helping to build country capacity.11 24. First, the GEF Council has authorized the GEF Secretariat to provide direct grants to countries of up to $500,000 for enabling activities and to provide support for "National Portfolio Formulation Exercises", which are helping countries to formulate their plans for GEF-5. The CEO of the GEF is now allowed to sign agreements with countries on behalf of the World Bank after exercising all proper preparations and ensuring safeguards. The GEF Evaluation Office is planning a mid-term review of this new modality at the end of 2012 or the first half of 2013. 25. Second, the GEF Council decided in November 2010 to initiate a pilot program of accrediting additional agencies — to be called GEF Project Agencies — beyond the initial 10 implementing and executing agencies. It approved the broad principles governing this pilot program in May 2011,12 including an accreditation process for organizations seeking to become GEF Project Agencies. Some of these are envisaged to be national institutions. The GEF Evaluation Office will also conduct a mid-term review of this pilot program two years after the first five agencies have been accredited. Based on the findings of this evaluation, the Council will then decide “whether to continue accrediting GEF Project Agencies and whether or how the accreditation policies and procedures should be amended.� GEF Evaluation Arrangements 26. The GEF Council gave early attention to monitoring and evaluation (M&E), and the GEF has commissioned an Overall Performance Study at the end of each replenishment period. The first three studies, which were completed in 1999, 2002, and 2005, were contracted to external teams of evaluators. The fourth study, completed in 2010, was conducted internally by the GEF’s own independent evaluation office, which was established in 2003. Indeed, the GEF is the only GRPP in which the World Bank is involved that has so far established an independent evaluation office that reports directly to the program’s governing body, in this case the GEF Council.13 27. Each GEF agency is responsible for undertaking the terminal evaluations of the GEF- financed projects that it supervises. The GEF Evaluation Office, in turn, has the central role of ensuring the independent evaluation function within the GEF, setting minimum 11. This having been said, the GEF has not formally subscribed to the 2005 Paris Declaration, unlike the Global Fund and GAVI. The GEF Council decided in 2009 that it would show “continued support� for the Paris Declaration principles. 12. GEF, 2011, “Broadening the GEF Partnership Under Paragraph 28 of the GEF Instrument,� GEF/C.40/09. 13. The Consultative Group on International Agriculture Research is also in the process of establishing an interdependent evaluation arrangement. Appendix L 92 requirements for project-level M&E, ensuring oversight of the quality of M&E systems on the program and project levels, and sharing evaluative evidence within the GEF. 28. The Evaluation Office also conducts Annual Performance Reviews and independent evaluations that involve a set of projects from more than one implementing or executing agency. These evaluations are typically on a strategic level, on focal areas, or on institutional or cross-cutting themes. The GEF Evaluation Office also supports knowledge sharing and follow-up of evaluation recommendations. It works with the GEF Secretariat and the implementing and executing agencies to establish systems to disseminate lessons learned and best practices emanating from M&E activities, and provides independent evaluative evidence for the GEF knowledge base. 29. The GEF Council approved a formal Monitoring and Evaluation Policy in 2006, and a revised policy in 2010. The 2006 policy affirmed the independence of the Evaluation Office and its direct link to the Council, established the responsibility of the GEF Secretariat and GEF Agencies for monitoring at the portfolio and project levels, and contained minimum requirements for M&E for GEF-funded activities. The main revisions in 2010 included “reference to the new GEF results-based management and other major policies introduced with GEF-5, a better definition of roles and responsibilities for the different levels and typologies of monitoring, [and] a stronger emphasis on country ownership and the role of the GEF focal points in monitoring and evaluation.�14 14. GEF Evaluation Office, 2010, The GEF Monitoring and Evaluation Policy 2010, p. vi. 93 Appendix M Appendix M. The World Bank’s Programs in the Health Sector Overview of the Bank’s Country-Based Model 1. Since the reorganization of the Bank in 1996 in accordance with a matrix structure,15 the Bank’s operational involvement in each client country has been based on a Country Assistance Strategy (CAS), now called a Country Partnership Strategy, negotiated between the Bank’s country team working on that country and the government. Headed by a country director and a country economist, the team also comprises staff working in the various sectors of the economy, such as agriculture and rural development, urban development, education, health, finance, energy, transportation, and water. Each sector has to compete for its place in the CAS in accordance with the agreements reached between the country director and the government on the priority sectors for Bank support to the country. 2. The CAS lays out a set of activities that the Bank will support over the next three to four years, comprising both analytical and advisory work (AAA) and lending products, including ongoing activities and those to be initiated during the CAS period. The CAS is itself based on sectoral and economywide analytic work supported by the Bank, such as Public Expenditure Reviews. Depending on the income level of the client, “lending products� include IBRD loans at market rates of interest, concessional loans (such as IDA credits), and grants (such as IDA grants, GEF grants, and a growing number of other grant instruments financed by global, regional, and country-level trust funds).16 AAA products include economic and sector work and technical assistance. 3. Except in post-conflict situations where there is no functioning government, lending products are normally implemented by a government department or agency, although governments may enlist NGOs and CSOs to help implement the project — and almost always do so in the case of HIV/AIDS projects. The implementing agency for each project, which usually includes a project implementation unit embedded in the government department, is agreed during project preparation. An institutional assessment of the proposed project implementation unit is conducted as part of the appraisal process, and the project provides capacity-building support if needed. 4. Each project has a project manager who is responsible for preparing the project from the point of view of the Bank and for supervising the subsequent implementation of the project with the support of his/her task team. Project managers are also directly responsible 15. The six Regional vice presidencies comprise the columns of the matrix, and the sectoral and thematic networks comprise the rows. The country director has control over the budget for each country program (both the administrative budget and the lending budget) but “no staff.� The country director must “purchase� staff time from the sectoral and thematic networks to undertake the agreed activities in the CAS. 16. The Bank raises funds on international capital markets for its IBRD loans to middle-income countries, and mobilizes donor funds to replenish IDA every three years. The GEF also mobilizes donor funds to replenish its resources every four years. Resource mobilization is less systematic for other trust funds that are financing investments at the country level (such as the Education for All–Fast Track Initiative, the Climate Investment Funds, and the Global Agriculture and Food Security Program). Appendix M 94 for overseeing and, in some cases, personally executing AAA products that are financed by the Bank’s administrative budget, as well as some that are financed by trust funds (termed Bank-executed trust fund activities). This involves drafting terms of reference, directly recruiting consultants to undertake the work, and ensuring that the work is completed. The majority of trust-funded AAA are, however, “recipient-executed,� like Bank lending products. In these cases, the recipient is responsible for recruiting consultants and purchasing goods and services, in accordance with the Bank’s procurement guidelines and under the supervision of the project manager. The Bank requires an allocation of Bank budgetary or trust fund resources for all activities carried out by staff, including the provision of technical support. 5. The majority of Bank project managers are now based in the field, either in the recipient country itself or in a neighboring country, as a result of the Bank’s decentralization process, which began in 1997. About 45 percent of the Bank’s regional HNP staff are now located in country offices, rising to 62 percent in South Asia and 66 percent in East Asia (Table M-1). Where the project manager is not based in the country, supervision involves multiple missions over the five–seven-year life of the project, with the assistance of a range of specialized consultants. Table M-1. Location of World Bank HNP Sector Staff, as of June 2011 Field-based in Country Share in Share in Offices Country Country Internationally Nationally Offices (HNP Offices (Bank- recruited recruited HQ-based Total sector) wide) East Asia & Pacific 5 15 9 29 69% 75% South Asia 7 16 14 37 62% 70% Africa 18 19 46 83 45% 64% Europe & Central Asia 1 9 15 25 40% 57% Middle East & N. Africa 1 2 7 10 30% 45% Latin American & Caribbean 6 0 21 27 22% 40% Subtotal 38 61 112 211 47% 61% HNP Anchor 0 0 45 45 0% 0% Total 38 61 157 256 39% 39% Source: World Bank data. 6. If the Bank is actively engaged in the health sector of the country, this will be reflected in the size of the project portfolio, which in turn will be reflected in the quantity and quality of Bank-supported analytical work in the country—that is, the Bank is more likely to have supported studies to provide the evidence base for Bank-financed projects in the country. Such analytical work is usually done in concert with the government and other donors, in which case there is joint determination of the scope of the analytical work and cost-sharing. 7. In principle, the Bank attempts to help country clients formulate an evidence-based, comprehensive national health strategy and plan, typically spanning five years. The greater 95 Appendix M the Bank’s engagement in the country, such as the size of the lending portfolio, the more important it is for the Bank to ensure the quality of the national strategies and action plans, and for country clients to have high ownership of these processes and products. In countries with multiple donors, and where health is a priority sector (as in many IDA countries in Africa), donor coordination mechanisms exist, but they vary considerably in nature and effectiveness. These mechanisms attempt to bring together some or all of the development- partner agencies active in the sector, including bilateral donor-partners, multilateral development banks, foundations (Gates and Clinton), WHO, UNICEF, and large NGOs to harmonize procedures, avoid duplication, and collaborate. 8. About a decade ago, a new approach —the Sector-Wide Approach (SWAp)—was introduced by the World Bank and other donors as a means to overcome inefficiencies, reduce transactions costs to the country, and bring better development results.17 SWAps embraced the principles of harmonization and alignment that were later endorsed by the 2005 Paris Declaration on Aid Effectiveness. They represented a shift in the relationship and behavior of donors and governments, with all parties jointly supporting nationally defined health programs through parallel or pooled financing general budget support, or a combination of the two. Health SWAps represented higher and more committed levels of donor support and coordination with a country’s overall development program in the health sector. 9. Between FY1997 and FY2010, the World Bank approved 41 HNP projects supporting health SWAps in 32 countries (Figure M-1). Thus, in the 14 years following the launch of the approach, about 11 percent of all (385) approved HNP projects supported a SWAp. Sixty percent (25) of the projects that supported health SWAps were in Sub-Saharan Africa, six were in South Asia, four were in East Asia and the Pacific, three were in Latin America and the Caribbean, and one was in Eastern Europe and Central Asia. Support for health SWAps is mainly found in low-income countries, accounting for a fifth of HNP projects approved in low-income countries (LICs), compared with only 9 percent of those in lower-middle-income countries. Health Sector Strategies and Bank-Wide Initiatives in Relation to Communicable Diseases and Health Systems Strengthening 10. The World Bank launched a comprehensive strategy for health in September 1997: the Health, Nutrition, and Population (HNP) Sector Strategy. The Strategy was clear about the Bank’s role in health, citing its comparative advantage as its ability to work across multiple sectors and to conduct country-specific research and analysis in support of programs to which it could bring significant financing. The Strategy did not view the Bank as having a comparative advantage in communicable disease control expertise, epidemiology, and the like in comparison with WHO, UNICEF, and UNAIDS. The Bank would focus on the broader aspects of health such as systems stewardship and oversight, systems performance, and health financing. 17. Denise Vaillancourt, “Do Health Sector-Wide Approaches Achieve Results? Emerging Evidence and Lessons from Six Countries, IEG Working Paper 2009/4. Appendix M 96 11. With a portfolio of 154 active and 94 completed HNP projects, for a total cumulative value of $13.5 billion (1996 prices), the Bank had become the largest single source of donor financing in HNP. The Strategy identified three priority areas (a) to improve health outcomes for the poor; (b) to enhance performance of HNP services; and (c) to improve Figure M-1. The Evolution of World Bank Lending for Health SWAps, FY1997–2011 US$ Millions No. of Projects 700 8 600 7 6 500 5 400 4 300 3 200 2 100 1 0 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Source: Denise Vaillancourt (2009), “Do Health Sector-Wide Approach Achieve Results: Emerging Evidence and Lessons from Six Countries, IEG Working Paper 2009/4, for FY1997 to FY2008, and now updated through FY2011. Note: These 41 projects had the following characteristics in their design documents: (a) explicit support of a SWAp; (b) appear to support a program or SWAp, but without explicit reference to a SWAp; or (c) provide for the pooling and joint management of donor funding. Among projects included in the initial list, those that were retained had: (d) mechanisms for coordination between the government and donors, and among donors; and (e) a common M&E framework for measuring program performance used by most donors and government and a mechanism for joint reviews of program performance. health care financing. It viewed investing in communicable disease control in the context of poverty alleviation, since communicable diseases disproportionately affected the poor, and the poorest 20 percent of the population experienced about 60 percent of all deaths from communicable diseases. Many who fell ill but did not perish had lowered productivity, spent high out-of-pocket costs for treatment, and became impoverished. Thus, while HSS was the 97 Appendix M Bank’s comparative strength, improving health outcomes for the poor also justified support for communicable disease control.18 12. Citing the success of the Onchocerciasis Control Program, the 1997 HNP Strategy also recognized the value of partnerships. It would join forces with WHO, UNAIDS, and others to fight HIV/AIDS, tuberculosis, and malaria. The Strategy also mentioned the importance of partnerships that were not disease-specific, such as the Global Forum for Health Research. 13. In the mid-1990s, as the burden from communicable diseases— especially from HIV/AIDs, tuberculosis, and malaria—increased, a growing number of donors, including the Bank, invested in single-disease projects. The Bank issued an expanded Africa HIV/AIDS Strategy in June 1999—Intensifying Action against HIV/AIDS in Africa: Responding to a Development Crisis.19 The Strategy saw AIDS as the foremost threat to development and to society as whole in the Region. Incredible numbers of African adults, in the prime of their working and parenting lives, were dying, which had a profound impact on the workforce and left behind millions of orphans. The Strategy had four pillars:  Advocacy to position HIV/AIDS as a central development issue and to increase and sustain an intensified response  Increased resources and technical support for African partners and Bank country teams to mainstream HIV/AIDS activities in all sectors  Prevention efforts targeted to both general and specific audiences, and activities to enhance HIV/AIDS treatment and care  Expanded knowledge base to help countries design and manage prevention, care, and treatment programs based on epidemic trends, impact forecasts, and identified best practices. The AIDS Campaign Team- Africa (ACT-Africa) was established in the Office of the Africa Regional Vice-Presidency. 14. The next year, the Bank launched a US$1 billion MAP to provide grants to countries where AIDS was most threatening (Table M-2). The Bank’s Board approved the first MAP in September 2000, providing $500 million in IDA credit for financing HIV/AIDS projects in Africa. The Bank also earmarked $155 million to fight AIDS in the Caribbean. The Board approved the second $500 million envelope in February 2002. The second MAP provided 18. An IEG portfolio review of Bank lending for communicable disease control (IEG Working Paper 2010/3) found the reasons most often cited by the Bank for its involvement in communicable disease control were: (a) the Bank was the financier of last resort in “donor-poor� countries; (b) the Bank’s convening power, policy influence, and leadership were needed; and (c) the technical quality of Bank experience in project preparation, design, and M&E. 19. Previous Bank strategies to address AIDS in Africa included AIDS: The Bank’s Agenda for Action in 1988; Combating AIDS and Other Sexually Transmitted Diseases in Africa: A Review of the World Bank’s Agenda for Action in 1992; the Regional AIDS Strategy for the Sahel in 1995; AIDS Prevention and Mitigation in Sub- Saharan Africa: An Updated World Bank Strategy in 1996. See IEG 2005, Box 2.1 on page 14. Appendix M 98 support for the first time in the form of IDA grants, and allowed financing of antiretroviral treatment.20 15. The MDGs of 2000 put health in the forefront, and MDGs 4 and 5 targeted reduction of communicable diseases. The MDGs also underscored the value of partnerships (MDG 8). The Bank endorsed the MDGs not long after their adoption. Table M-2. Multi-country AIDS Program (MAP) Projects, by Region and Approval Year Year of Approval 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Number of Projects Africa 7 9 5 9 5 4 6 4 2 3 54 Caribbean 2 1 3 2 3 1 1 13 Total 9 10 8 11 8 4 6 5 3 3 67 Commitments (US$ millions) Africa 287.2 262.3 172.8 355.9 80.0 247.7 185.4 65.8 55.0 55.0 1,767.1 Caribbean 40.2 15.0 30.1 19.0 21.4 10.0 35.0 170.6 Total 327.4 277.3 202.9 374.9 101.4 247.7 185.4 75.8 90.0 55.0 1,937.7 Source: World Bank data. Note: All projects except one are mapped to the HNP Sector Board. (One Mali project, approved in 2004, was mapped to the Finance and Private Sector Development Sector Board.) 16. The Bank issued Rolling Back Malaria: the World Bank Global Strategy and Booster Program in June 2005, which provided the basis and rationale for initiating a five-year “Booster Program� for malaria control. Recognizing that the pace of gains in controlling malaria had not been as quick as expected since the Abuja Summit of 2000, the Booster Program was the Bank’s response as a member of Roll Back Malaria partnership, to assist in “scaling-up for impact.� Five key points underpinned the program: (a) the program would be country led; (b) it would emphasize both effective scale-up of interventions and the strengthening of health systems; (c) it would operate through partnerships; (d) it would provide flexible, cross-border, and multisector funding; and (e) it would monitor results against monies spent. The program envisaged $500– $1,000 million in new commitments for malaria control over five years. 1.1 A decade after its 1997 HNP Strategy, the Bank issued a new HNP Strategy in September 2007. The new Strategy reaffirmed the Bank’s comparative advantages in the following areas: (a) its capacity in health systems strengthening (including health financing, insurance, demand-side interventions, regulation, and systemic arrangements for fiduciary and financial management); (b) its intersectoral approach to country assistance; (c) its advice to governments on regulatory frameworks for private-public collaboration in the health sector; (d) its capacity for large-scale implementation of projects and programs; (e) its 20. For IDA 13 (2003–05), donors agreed that 18-21 percent of IDA resources should be provided on a grant basis. All AIDS projects or components approved in low-income countries since April 2003 have been eligible for IDA grants, as have 25 percent of AIDS projects or components in blend countries (those eligible for both IDA credits and IBRD loans). 99 Appendix M convening capacity and global nature; and (f) its pervasive country focus and presence (World Bank 2007c, pp. 17–18). 1.2 The 2007 Strategy underscored a focus on results: that is, in health outcomes in addition to operational modalities. It reiterated the contribution of multisectoral approaches and interventions to improve health outcomes, such as safe drinking water and household sanitation, among other health infrastructure investments. It did not see a contradiction between Bank support for health systems and support for the control of priority diseases. Bank investments were seen as necessary to ensure synergies between health system and single-disease approaches, especially in low-income countries where fighting communicable diseases was still a priority. The Strategy also recognized the growing need to support interventions against non-communicable diseases. 17. The result of these various initiatives in relation to communicable diseases is summarized in Table M-3. Bank lending for communicable disease control accounted for 38 percent of HNP projects and 33 percent of HNP commitments between 1997 and 2010 inclusive. Table M-3. World Bank Communicable Disease Projects and Commitments, FY1997– 2011 Project Type Approved Projects Commitments Number Share US$ millions Share Freestanding communicable disease projects 112 74% 6,580 90% Single disease projects 97 64% 4,989 69% HIV/AIDS 70 46% 2,735 38% Tuberculosis 3 2% 374 5% Malaria 5 3% 547 8% Avian influenza 7 5% 65 1% (H1N1) Influenza 5 3% 723 10% Cholera 1 1% 15 0% Leprosy 1 1% 32 0% Polio 4 3% 474 7% Schistosomiasis 1 1% 25 0% Multiple disease projects 15 10% 1,591 22% Projects with a communicable disease component 40 26% 696 10% Total number of communicable disease projects 152 100% 7,277 100% Total number of HNP projects 423 22,729 Share of HNP projects 36% 32% Source: For FY1997–2006, Gayle H. Martin, 2010, Portfolio Review of World Bank Lending for Communicable Disease Control, IEG Working Paper 2010/3. Updated by IEG through FY2011 from World Bank databases. Note: The full project commitments are included for freestanding communicable disease projects, and only the commitments to the communicable disease component for projects with components. Therefore, these commitments are somewhat larger than those in Table 3 in Chapter 2. Appendix M 100 18. The 2007 Strategy found that the HNP partnership portfolio had become fragmented with a multiplicity of GRPPs, and needed “stronger strategic direction.� The Strategy stated that the HNP sector would practice greater selectivity when deciding to participate in partnership programs: (a) to complement Bank work in areas in which it has no comparative advantages or to complement other partners needing Bank expertise — all of direct benefit to client countries; and (b) to contribute to the international community support of global public goods and prevention of global public “bads.� The Strategy also proposed the establishment of a Global Health Coordination and Partnership Team in the HNP Anchor to coordinate partnerships, facilitate selective fund raising and trust fund management, DGF management support, selective joint ventures around comparative advantages, and harmonization. This team has not, however, been established, but a senior partnerships adviser post has been created. 19. The 2007 Strategy repeatedly states that the World Bank would strengthen its engagement with the Global Fund, particularly in low-income countries. However, it does not articulate how this engagement would take place, except for reaching “specific agreements with WHO and the Global Fund on a collaborative division of labor at the country level� in a box on “Next Steps for Implementation.� 20. The 2007 Strategy acknowledged that the global HNP aid architecture had changed significantly since 1997, with many new players entering the field, such as GAVI, the Global Fund, and several foundations, bringing with them innovative financing mechanisms, mostly earmarked for specific diseases or issues. The Strategy recognized that the Bank was no longer the largest external financier of investments in the HNP sector in developing countries, as it had been 10 years earlier. 21. In March 2009, a progress report to the Board on implementation of the 2007 HNP Strategy underscored HSS and the importance of strengthening the HNP portfolio. It cited examples of results-based funding, underscored the multisectoriality of HNP support, mentioned that about one-half of Poverty Reduction Support Credit operations had an HNP aspect, and stressed cooperation with other development partners in the context of IHP+. IEG Health Sector Evaluations 22. IEG has issued three evaluations of the development effectiveness of the Bank’s support for HNP since 1997. The first evaluation, in 1999 — Investing in Health: Development Effectiveness in the Health, Nutrition, and Population Sector — found that the Bank had been more successful in expanding health service delivery systems than in improving service quality and efficiency or achieving policy and institutional change. There was little evidence of the impact of Bank investments on health outcomes because of underdeveloped M&E systems and excessive focus on inputs. The lending portfolio had grown rapidly, and many complex projects had been approved in countries with the weakest institutional capacity. The evaluation recommended that the Bank (a) increase its strategic selectivity, (b) focus on enhancing the quality of intersectoral interventions and AAA, (c) strengthen quality assurance and results orientation, and (d) build strategic alliances with other development partners. 101 Appendix M 23. The second evaluation, in 2005 — Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance — found that the Bank had contributed to raising political commitment, enhancing and improving access to services in the fight against HIV/AIDS. However, evidence of results in changed health behaviors and improved outcomes was limited because of a failure to monitor and evaluate. The evaluation found that the political commitments needed to be broadened and sustained, and Bank projects needed to invest in the capacity of civil society to design, implement, and evaluate AIDS interventions. It also noted that projects had underinvested in prevention programs for high-risk groups. IEG recommended that the Bank (a) be more strategic and selective, focusing on efforts likely to have the largest impact for their cost; (b) strengthen the capacity of national and subnational AIDS institutions to manage the long-term response; and (c) invest in M&E capacity and incentives to improve evidence-based decision making. 24. The third evaluation, in 2009 — Improving Effectiveness and Outcomes for the Poor in Health, Nutrition and Population — assessed the efficiency and effectiveness of the Bank Group’s direct support for HNP to developing countries since 1997 and drew lessons to help improve the effectiveness of this support in the context of the new aid architecture. The major findings were as follows:  Although the Bank Group now funds a smaller share of global HNP support than it did a decade ago, its support remains significant and the Bank continues to play an important role and add value in HNP.  About two-thirds of the Bank’s HNP projects show satisfactory outcomes, but one- third did not do well, mostly due to the increasing complexity of HNP operations, inadequate risk assessment and mitigation, and weak M&E.  The accountability of Bank Group investments for results for the poor has been weak. The Bank’s investments often have a pro-poor focus, but their objectives need to address the poor explicitly and outcomes among the poor need to be monitored. 25. The evaluation also reviewed findings and lessons for three major approaches to improving HNP outcomes — communicable disease control, health reform, and SWAps — that have been supported by the Bank as well as the international community over the past decade. These approaches are not mutually exclusive. 26. The evaluation found that support for communicable disease control can improve the pro-poor focus of health systems, but excessive earmarking of foreign aid for communicable diseases can distort allocations and reduce capacity in the rest of the health system. Bank support has directly built country capacity in national disease control programs as dedicated communicable disease projects have dramatically increased as a share of the overall portfolio since 1997. Support for communicable disease control, with the exception of AIDS projects, has shown better outcomes in relation to objectives than the rest of the HNP portfolio. It was particularly important to address both equity and cost-effectiveness in HIV/AIDS programs, given the huge commitments to that disease, and because HIV does not always disproportionately strike the poor, unlike tuberculosis and malaria. Care should be taken to ensure that progress on communicable disease control remains a priority as the Bank enhances its support to system-wide reforms and SWAps. Appendix M 102 27. The evaluation found that the SWAps have contributed to greater government leadership, capacity, coordination, and harmonization within the health sector, but not necessarily to improved efficiency or better health results. The focus of SWAps has been to promote consensus around a common national strategy; country leadership; better harmonization and alignment of partners; joint monitoring; the development and use of country systems; and, in many cases, the pooling of funds. The evaluation found that SWAps have been most effective in pursuing health program objectives when the government is in a leadership position with a strongly owned and prioritized strategy. Country capacity has been strengthened in the areas of sector planning, budgeting, and fiduciary systems. However, weaknesses have persisted in the design and use of M&E systems. Evidence is thin that the approach has improved efficiency or lowered transaction costs, because neither has been monitored. Adopting the approach does not necessarily lead to better implementation or efficacy of the government’s health programs. SWAps have often supported highly ambitious programs, involving many complex activities that exceeded the government’s implementation capacity. Programs need to be realistic and prioritized, and the processes of setting up SWAps should take care not to distract the players from a focus on results and from ensuring the implementation and efficacy of the overall health program. Table M-4. Comparing the Global Fund and the World Bank Feature World Bank Global Fund Basic nature The World Bank is both a financing instrument and, The Global Fund is a “financial instrument, not an to some extent, an implementing agency, in the implementing agency.� It is a foundation with sense that it actively supervises projects that are specific purposes, created in 2002. implemented by government agencies. Governance The World Bank is an international development The Global Fund is a Global Partnership Program bank, an intergovernmental organization with a full- and an expression of the new multilateralism. It is time Executive Board that operates largely by legally incorporated as a Swiss foundation. It has an consensus. Created in 1944 at the Bretton Woods inclusive stakeholder Board with representatives Conference, its membership is restricted to country from private foundations, CSOs, and affected governments, its shareholders. With the communities, in addition to governments. WHO, establishment of IDA in 1960, donor and beneficiary UNAIDS, and the World Bank are nonvoting countries were divided into Part I and Part II members. The World Bank is the trustee of the countries. Global Fund financial resources. Resource The World Bank mobilizes donor funds to replenish The Global Fund mobilizes resources using a mobilization IDA every three years for concessional loans to low- periodic replenishment model on a voluntary basis income countries and raises funds in the for all public donors, complemented by ad hoc international financial markets to fund its loans to contributions from other donors. The third middle-income countries. It also manages trust replenishment, which concluded in October 2010, funds furnished by governments and private parties. raised $11.7 billion for the 2011–13 period. The Global Fund also raises funds through innovative financing mechanisms such as Product RED and Debt2Health. Terms of IBRD loans and IDA credits. Some IDA grants. Grants. assistance Country The World Bank provides IDA credits and grants to The Global Fund focuses on low-income (IDA- eligibility low-income countries, and IBRD loans to middle- eligible) countries. Middle-income countries must income countries. Funds are normally only provided focus grant proposals on poor and vulnerable to governments. populations in their countries and meet Global Fund cost-sharing requirements. 103 Appendix M Feature World Bank Global Fund Country Loans and credits are prepared jointly by the World The Global Fund supports programs “that reflect ownership Bank and the borrower and approved under legally national ownership and respect country-led binding conditions. formulation and implementation processes.� Country Strong country presence, depending on the size of Weak country presence. FPMs are not resident in presence the Bank’s country program. HNP project managers the country. Generally, LFAs exercise only fiduciary may be resident in the country. oversight of Global Fund grants. Technical The World Bank brings to bear strong technical Global Fund depends on development partners for capacity expertise at the country level. technical support. Country Lending and technical assistance activities are Grant proposals are based on local strategies for strategy based on a CAS and the HNP corporate strategy. control of the three diseases. The health sector has to compete with other sectors for its place in the CAS. Health strategy The Bank’s country-level health strategies are The Global Fund pursues an “integrated and expected to be consistent with the corporate HNP balanced approach covering prevention, treatment, Strategy, and health-specific economic and sector and care and support in dealing with the three work, such as Health Expenditure Reviews, diseases as defined in disease-specific strategies.� appropriately applied to the country’s circumstances. Basic approach Bank support is tailored to country circumstances Focused, disease-by-disease approach to to HNP and requests, in a dialogue with the country’s combating HIV/AIDS, tuberculosis, and malaria. The operations authorities. The Bank generally takes a sector-wide Global Fund is increasingly supporting HSS through approach to health sector development, focusing on Global Fund grants for disease control, since HSS HSS. It also supports communicable disease control assists in combating the three diseases. projects, especially HIV/AIDS projects, and coordinates health with related sectors such as nutrition, water and sanitation, infrastructure, public sector management, and macroeconomic and fiscal policy. Project Projects are identified and prepared collaboratively Grant proposals are prepared, reviewed, and preparation and by World Bank and government staff (usually from submitted by CCMs. Proposals are reviewed by the approval the Ministry of Health). Projects are appraised by a Technical Review Panel and approved by the World Bank mission, negotiated between the World Global Fund Board. Bank and the government, and approved by the World Bank Board. Oversight The Bank’s project manager oversees multiple The CCM oversees the preparation of proposals for stages of joint project preparation and appraisal. grant funding and the implementation of approved projects. New grant The World Bank sometimes uses program-based The Global Fund is shifting toward a single stream architecture approaches such as the Adaptable Lending of funding by disease in some countries. Program (APL). Implementation Implementing agency is almost always a The Principal Recipient (the implementer) can be a government department, such as Ministry of Health government agency, an international organization for health projects, and usually includes a project (such as UNDP), CSO, university, or other. implementation unit, embedded in the government department. Appendix M 104 Feature World Bank Global Fund Implementing The implementing agency is selected during the The Principal Recipient is nominated by the CCM agency project preparation and appraisal process. The after the grant proposal has been approved by the capacity of the implementing agency is an essential Global Fund Board. The LFA assesses the financial, aspect. administrative, and implementation capacity of the nominated Principal Recipient to implement the approved grant. Supervision A Bank project manager supervises the The FPM manages the grant from both a financial implementation of World Bank-supported projects, and programmatic perspective with the assistance a either resident in the country or by frequent country team and the LFA, who verifies and reports missions to the country. on grant performance. M&E M&E design is normally participatory, with M&E provides the basis for disbursement release stakeholder buy-in. M&E provides a partial basis for and to demonstrate results for future funding. Grant- disbursement release and a basis for lessons level M&E is not linked to overall performance learned for future use at both the country and evaluation. institutional levels. Role of CSOs CSOs are normally consulted on the CAS and may CSOs are represented on the CCM, help prepare be consulted when preparing health sector grant proposals, and may implement some Global strategies and Bank-supported projects. With Fund–funded activities as Principal Recipients, sub- concurrence of the implementing agency, CSOs recipients, or sub-sub-recipients. may implement some project activities, depending on project design. Role of other Other donors may co-finance Bank projects. The The World Bank and other donors participate in donors World Bank’s presence in the country may facilitate country-level health forums (disease-specific or donor cooperation. otherwise). They may also participate on the CCM and provide technical support to Global Fund– supported activities. While donor representation on the CCM varies from country to country, there is usually at least one representative of the donor community on the CCM. Role of WHO, The World Bank may invite technical partner Provide varying levels of technical support to the UNAIDS, Stop agencies to participate in identification, appraisal, CCM in preparing grant proposals and overseeing TB, and RBM and other missions. their implementation. Guidelines for The 2007 HNP Strategy provides general guidelines No specific guidelines addressed at the World Bank. World Bank– on engaging with the Global Fund. There are no Senior Global Fund staff encourage the CCMs and Global Fund Bank-wide directives that have operationalized FPMs to engage actively with the World Bank engagement these guidelines. HNP sector managers may country office and field health staff. encourage project managers to engage with the Global Fund in their countries. MOU No MOU with the Global Fund on engaging with the No MOU with the World Bank on engaging at the Global Fund at the global or country level. global or country level. Professional Project managers are normally health economists, FPMs are generalists based at Headquarters who backgrounds health policy specialists, or public health specialists manage three-to-four country grant portfolios and and roles of and are generally responsible for health projects supervise by means of frequent trips to the project from identification through appraisal and execution countries. managers and to project completion and loan/credit closing. FPMs 105 Appendix N Appendix N. IEG Assessment of the Independence and Quality of the Five-Year Evaluation Topics / Criteria Findings 1. Oversight and Management of the FYE by the Global Fund Board and the Technical Evaluation Reference Group (TERG) Background to  The FYE was conceived as part of an M&E Strategy adopted by the Board in 2003. Evaluation:  The Strategy called for: M&E Strategy, o Development of an M&E Operations Plan Operations Plan, and the FYE o A review of the Global Fund’s overall performance against its goals and principles after one full cycle of grants had been completed o Creation of an external body to advise, assess, and oversee the Global Fund’s work on M&E and to provide independent advice and assessment to the Board.  Within the Secretariat, the Strategic Information and Measurement Unit (SIMU) was responsible for managing the implementation of the M&E Operations Plan. The SIMU reported directly to the executive director, allowing for some degree of separation and independence from the Portfolio Management Group, which manages the country programs. Role of TERG  Conflicted role of TERG. It was to serve as independent advisory body to the Global Fund Board on evaluation matters and to provide oversight of Global Fund–commissioned evaluations.  TERG was also mandated to advise the Secretariat on evaluation approaches and practices of a technical and managerial nature and to monitor Global Fund progress toward corporate M&E goals.  This potential conflict was recognized. At Board and MEFA Committee meetings, the debate over an internal or external evaluation function finally concluded in a compromise. The Global Fund would have an internal M&E unit (SIMU) that handled the M&E work and may also commission external studies and an external and independent technical advisory body that reported directly to the Board. On quality and technical issues of evaluation, the internal body would still defer to the external body. This was considered the best balance of supporting a culture of self-correction and learning within the Global Fund, while at the same time having an independent evaluation capability.  TERG was responsible for the oversight of the FYE. It was responsible for directing all contractual activities, including drafting and approval of all terms of reference. Independence of  TERG reaffirmed its role in ensuring the independence and technical soundness of the FYE. TERG oversight TERG confirmed that it was the ultimate signatory on all products of the FYE. Early design  Highly consultative, participatory, and inclusive process (360 Degree Stakeholder Assessment) to stage: conceptualize evaluation topics, closely steered by TERG. Consultation  First, High-Level Stakeholder Consultation with 23 experts to formulate the first Round of process and Overarching Questions on Principles and Practices, Partnerships, Results and Impact. conceptualization  Next, Online Stakeholder Survey, with targeted e-mailing to more than 5,000 contacts. More of evaluation broadly, visitors to the site could participate in the open survey put on the Web site. Nine hundred issues and completed questionnaires were received on 23 attributes of the Global Fund. questions  Results were presented and refined at Global Fund Partnership Forum in Durban, S. Africa.  There was broad-based support for FYE and agreement on evaluation topics. Appendix N 106 Topics / Criteria Findings Evaluation Plan  Consulting firm assembled to draft Master Evaluation Plan or Framework for FYE. and Evaluation  Senior evaluation officer with in-depth knowledge from Global Fund assigned to assist the firm. Framework  TERG closely supervised the drafting process. The firm developed what was eventually called the Technical Background Paper. It identified and recommended on data sources, studies to be conducted, country visits, staffing and costs, competencies of the consultants, and communications strategies. It also proposed methodologies and options for implementation, timelines, and budgets.  Proposed the conduct of three separate studies (Organizational Effectiveness of the Global Fund; Effectiveness of Partner Environment at Country Level; and Effects of Increased Resources on Burden of Diseases) and a Synthesis Report.  Based on this background paper, TERG proposed an Evaluation Framework to Board for adoption in November 2006.  Budget proposed was 0.6 percent of all funds disbursed to date.  Other development agencies (PEPFAR, USAID, UNAIDS) were invited to TERG planning meetings Requests for  Requests for proposals and terms of reference for contracting of the final evaluation teams proposals and closely followed the guidelines in the Technical Background Paper. selection of  Evaluation Consortium was selected by TERG, whose role was to implement the Evaluation contractors Framework and Plan. Evaluation Consortium was to adhere as closely as possible to Evaluation Plan.  There was a limited pool of evaluation expertise suited for Study Area 3. This resulted in a TERG member from WHO resigning his position and taking his place as a member of the Evaluation Consortium when the Study Area 3 contract was awarded to a team comprising members from MACRO, WHO, Harvard, Johns Hopkins, and the African Center for Development Research. Transparency of  All information about the evaluation process, including who had commissioned it; how it was evaluation managed and funded; the reporting and review process; and budget assigned was reported in process detail in the Technical Background Paper, which was posted on the Web. Adequacy of  TERG made the FYE its primary responsibility. Enormous TERG and Secretariat resources were resources to expended. support TERG  Three full-time Secretariat staff with evaluation background were assigned to assist TERG during the oversight FYE.  The Secretariat eventually ring-fenced the staff and kept them out of the loop of regular Secretariat functions to avoid conflict of interest and ensure arms-length distance between TERG and the Secretariat. Independence of  The FYE was an independent product without interference from the Global Fund. FYE  However, MACRO perceived TERG oversight as highly burdensome and requiring excessive reporting. External factors  At times TERG challenged MACRO on its approach or methodology in Study Area 2. influencing FYE  TERG felt such tight oversight was necessary to ensure good-quality evaluation. management  Not only was TERG the oversight body for the FYE , it was also the advisory body on evaluation to the Board.  Time and again, the Global Fund Board noted its satisfaction with TERG’s role as oversight body.  During the course of the FYE, the Global Fund went through some structural and senior management changes. These internal structural changes, in themselves a decisive and impactful undertaking, led to new ways of doing things. These included greater separation or fire-walling by 107 Appendix N Topics / Criteria Findings the Global Fund Secretariat of Secretariat functions/staff from TERG.  TERGs oversight was further challenged by the deteriorating TERG- Secretariat relationship. Review, feedback  All FYE reports were completed and submitted to 18th Board meeting in May 2009. process  The review and reporting process was open and transparent.  Evaluation reports were submitted to the Board through TERG, which kept the Board regularly apprised of findings.  TERG often formulated its own recommendations to the Board, some of which differed from the FYE.  The Secretariat was invited by TERG to comment on findings as they came in.  TERG summary reports accompanied the original MACRO reports during submissions to Board. Board and  A formal Board Response to the FYE is still pending. Preparation of the formal response has management been relegated to an Ad Hoc Board Committee (from Finance & Audit, Policy & Strategy, Country response Program Portfolio committees).  Meanwhile, the Board had directed the Secretariat to implement recommendations of FYE and TERG.  The Management Response is available on the Web site, although it is not placed with Evaluation reports, which are listed under TERG evaluations.  An updated Management Response was prepared in March 2010 to inform the Third Replenishment Meeting of the Global Fund. 2. Participation and Inclusion  As a reflection of Global Fund’s commitment to country ownership, the FYE placed countries at the center of the evaluation. Country-level mechanisms were established to coordinate impact measurement activities for Study Area 3. At the preparatory stage they consumed time and resources to set up and generated a lot of expectations from participating countries. A great deal more effort was needed during the actual evaluation process to utilize them optimally. The guiding  The guiding principles were closely adhered to during the FYE. Having a stakeholder governance principles of the model, the Global Fund spent considerable resources to ensure the FYE was consultative, FYE were (a) inclusive, participatory, and fully legitimate as an evaluation. inclusive process,  When the evaluation framework was conceptualized, a highly consultative and inclusive process (b) country was followed that extended beyond the Global Fund’s immediate stakeholder base. A 360 focused/led, (c) Degree Stakeholder Assessment was undertaken that included a (a) high-level expert build country stakeholder consultation; (b) targeted e-mailing of a structured survey to 5,000 stakeholders and evaluation an open solicitation for comments and inputs on the Global Fund Web site; and (c) further capacity, (d) discussion at the Global Fund’s biennial Partnership Forum. Stakeholder response was very collaborate with high, as were expectations of the evaluation. local institutions, (e) share and disseminate as a local and global public good Inclusive and  The report from the Stakeholder Assessment was published, documenting the process followed consultative in and the stakeholder views/suggestions received about the evaluation. According to the report, design there was broad-based support for the FYE and agreement on its topics and priorities.  UNAIDS, PEPFAR, and USAID were consulted and invited to participate in the evaluation design. Appendix N 108 Topics / Criteria Findings Country-focused,  The FYE was participatory in its implementation approach and placed the country at the center of and participatory the evaluation. For one of the Studies, Study Area 3, Impact Evaluation Task Forces (IETFs), in implementation chaired by country clients, were formed in eight participating countries to coordinate all evaluation activities. These IETFs brought together relevant local expertise and institutions (government, civil society, international development partners, local research and teaching institutions) to facilitate and review the in-country work of the evaluation. Based on country knowledge, the IETFs proposed coordinated plans on impact evaluation for their respective countries.  Many local groups were subcontracted to undertake data collection and analysis under the management of MACRO. As stipulated in its Evaluation Framework, the FYE intended to have a developmental impact, and significant evaluation funds would be consumed in the participating countries.  The evaluation convened a Partners in Impact Forum to enable technical exchange between country (IETF representatives) and global partners involved in impact evaluation activities of the three diseases. The Forum served as a training workshop for data quality management and refined the proposed country impact evaluation plans. Learning and  Recipients/implementers of Global Fund grants, beneficiary groups, and other CCM members opportunities were eligible to serve on IETFs to facilitate learning and ownership by the CCM. “Linking� the IETFs with the CCM increased the risks of conflicts of interest. As reported by the evaluation report, this was not a good arrangement and necessitated “management of risks� to ensure independence of the country assessments. Managing  The above-mentioned mechanisms aimed at extending programmatic learning to the program potential conflicts and to country-level implementers and their beneficiaries during the FYE. But the IETFs needed of interest a level of engagement and management that could not be sustained by the evaluation team during the course of the FYE.  Expectations were high from TERG and IETFs about what could be achieved by these mechanisms. At the conclusion of the FYE, there was little ownership of the country-assessment studies by country-level stakeholders. Programmatic learning was not as high as expected. 3. Transparency, Disclosure, and Dissemination Openness of  The evaluation process was highly transparent. No other GRPP evaluation has achieved the evaluation level of transparency of the FYE. process  Regular presentations were made by TERG to apprise the Board and the Global Fund Findings Partnership Forum about evaluation findings. discussed at  Evaluation products, available only in English, were posted on the Web site. Both MACRO Board meetings reports and TERG reviews and critiques of the reports were prominently displayed. and the Partnership Forum  Primary data collected by Study Area 3 was posted on the Web. Web site dissemination Discussion of  Management of conflict of interest was not well articulated in the planning and design stages. conflict of interest  Requests for proposals did not discuss conflict of interest. Ideally conflicts of interest relating to in requests for evaluation team members should be disclosed in the final evaluation report, even if measures are proposals taken to mitigate their effects.  A TERG member from WHO (considered the best-placed person to evaluate the Study Area 3 report) resigned from TERG to become a principal member of the evaluation consortia. The conditions under which he was appointed and the measures taken to mitigate conflict of interest should have been described in the report.  There were no reported perceptions of conflict of interest on this particular arrangement. 109 Appendix N Topics / Criteria Findings Dissemination  The evaluation plan budgeted for dissemination activities of Study Area 3 country-level evaluation budget findings.  Workshops were held (some supported by WHO and USAID) to disseminate results and to train country stakeholders on the management and archiving of the micro-level data in the countries. 4. Study Area 1: Organizational Effectiveness and Efficiency of the Global Fund  Study Area 1 sought to determine whether the Global Fund, through its policies and operations, reflects its critical core principles in an effective and efficient manner, especially its role as a financial instrument rather than as an implementing agency.  The structure of the Study Area 1 evaluation report consisted of vision and mission, board governance, resource mobilization, effectiveness and performance of Global Fund architecture, institutional arrangements and workforce focus, process management and customer focus, measurement and knowledge management, and procurement.  Methodologically Study Area 1 was based on: (a) a study of Board Governance; (b) an organizational development assessment of the Global Fund/Secretariat; (c) a review of the proposal development process and the Technical Review Panel ; (d) an examination of procurement, supply management, and financial management issues; (e) private sector resource mobilization; (f) a management review of specific areas of performance and its ancillary structures, and benchmarking of a number of results and processes. 5. Building Evaluation Capacity Building  All the evidence collected from interviews with the Global Fund, evaluators, and country visits institutional suggested that this effort was largely unsuccessful. There appeared to be little evidence that the capacity in 18 specialized training, including country-specific data and knowledge, was being used and tapped countries by policy makers and other researchers as planned.  The FYE experience showed how difficult it was to incorporate systematic capacity building into an external evaluation. Care should be taken to ensure the evaluation function does not assume a secondary role to the learning function. The dynamics of completing a complex evaluation (described above) did not allow for building evaluation capacity, and ultimately there was not strong country ownership of the evaluation process and product in the eight Study Area 3 countries.  In the early preparatory days, through the IETFs and Partners in Impact Forum, good country participation was engendered. Country teams were hopeful and expectant of a good process and product. Country capacity  There was country appreciation of the initial gap analysis of country data and M&E systems.  At the minimum, capacity was developed in collection and analysis of primary data and surveillance.  One should be mindful, however, that skilled local capacity in evaluation exists but it is very difficult to tap due to the high costs (equivalent to international rates) and availability (engaged in other commitments). Provision for time  By and large, while the experience varied in countries, evaluation teams were not perceived to and effort to have taken the strengthening of national M&E systems seriously. When the execution pace ensure picked up, there was simply not enough time to effectively engage the IETFs and other national participation of processes and to build national ownership. key stakeholders Appendix N 110 Topics / Criteria Findings Applying Study  This was largely not achieved due to difficulty in synchronizing the timing of Study Area 3 Area 3 country country assessments with existing country review processes. results into the country health sector review and planning processes Country  In at least one country, as the evaluation rolled out, there was no consensus reached between ownership of country partners and external evaluators regarding methodology, definitions of service coverage, tools, approach, and quality of services. Country partners felt country-specific factors and knowledge were not concept, and adequately tapped or factored into the assessment. There were also differences of opinion about commitment to the assessment criteria applied by the evaluation team. subsequent  Another goal of the FYE was to package the tools and methodologies used into one model continuous use of evaluation platform that countries, already exposed to them, could continue to use. There is no the instruments indication yet (from the TERG report and country visits) that these methodologies and tools will used in the FYE be widely adopted by countries and their counterpart development agencies to conduct national- level impact evaluations.  The FYE was able to generate some collective action between PEPFAR, UNAIDS, and the Global Fund. These partners collaborated in the modeling and archiving of workshops of the Partners in Impact Forum. Developmental  The evaluation intended that the bulk of evaluation monies in Study Area 3 (US$11.7 million) approach of the would be used for country data collection, analysis, and capacity building. This was achieved with FYE the majority share of resources spent in the participating countries. Of the US$11.7 million, 40 percent was spent on data collection and analysis in countries and 30 percent on capacity building and technical assistance. The remainder was spent on administration (15 percent), development of instruments and tools (9 percent), and on analysis and reports (6 percent). 111 Appendix O Appendix O. Toward A Common Conceptual Framework for Assessing Country- Level Partnerships Assessment criteria and topics derived from a review of instruments used by Study Area 2 of the Global Fund, by UNAIDS, and by Phase 1 of the Paris Declaration. Examples and questions about the operating environment from these instruments are also presented. Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I A. Country Ownership Existence of Strategic Development Framework and Plans of Action  Grounded in AAA Existence of national strategies and plans National AIDS Council or Coordinating Existence of operational development  Plan of Action/ Implementation that of action for the three diseases. Authority and the National Strategic strategies — is costed Framework for AIDS — Number of countries with national Conduct partner/ stakeholder mapping development strategies (including  Sectoral plans aligned and exercise Poverty Reduction Strategies) that have consistent with overall national clear strategic priorities linked to a development strategy medium-term expenditure framework and  Owned by government and CSO reflected in annual budgets. and at subnational and provincial levels  Also owned foreign development partner agencies in the country Reliable country systems—e.g., number of partner countries that have procurement and public financial management systems that either (a) adhere to broadly accepted good practices or (b) have a reform program in place to achieve these. Appendix O 112 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I Relevant country-level governance and management arrangements for partnership program (e.g., CCM and National AIDS Coordination) That are inclusive and yet collectively Assess legitimacy of CCM membership (is Review the NAC and the extent of have the technical expertise and authority it inclusive and representative, with participation by national partners in the to direct and lead program activities members from academia; educational national AIDS strategic framework; their sectors; private for-profits; government; representation in the NAC. CSO and CBO; and people living with CHAT emphasizes the need for disease, e.g., AIDS, malaria, and multisectoral membership. tuberculosis; and religious /faith-based organizations; plus multilateral and bilateral organizations) A key principle of partnership in the Global Fund model is the inclusion and active participation of CSOs. CPA assesses how the Global Fund model has facilitated this over time Foreign development partner agencies Extent to which partners (local and Extent to which international partners are support fully the national authority international) on CCM effectively carry out supporting and cooperating with the NAC charged with leading the Program of their terms of reference or National AIDS Association Action Assess behavior and performance of CCM members with respect to composition and representation, legitimacy, governance and management, communication and reporting, transparency CCM Performance Assessment Need to manage adequately conflict of Assess legitimacy, representation, conflict policy, especially for investment of interest, ethical issues, effectiveness, programs. and efficiency of local governance and The same groups sitting on the grant- management entities. Policy on conflict of awarding body may be connected to interest (important for grant awarding ), 113 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I groups applying for investment grants especially for investment programs Assess role and contribution of CSOs: CPA tool assesses role of CSOs and their Their comparative advantage? contribution and effectiveness as CCM members and as Principal Recipients and How effective are efforts to increase sub-recipients CSO role? (This important assessment looks at point- of-service delivery – close to results) Examine factors that facilitate or act as barriers to country ownership of programs or their activities Do Global Fund policies and procedures respect country-led formulation and implementation of grants; assess which Global Fund policies and procedures actively promote country ownership Extent of external consultancy input or contracting-out proposal preparation, which may reduce country ownership of Global Fund grants Define country ownership from the perspective of local stakeholders and partners, assessing the extent of country ownership and alignment, and gather observations on ownership, alignment, and the Global Fund from key stakeholders B. Alignment Are development partner agencies Extent of alignment with national health Assess extent of alignment between Evidence of actions to reduce parallel supporting the right things? systems, existing M&E reporting and Global Fund HIV grants and Ministry of implementation structures; e.g., number procurement and financial management Health planning cycles (annual or of project implementation units in country systems biannual); alignment between Global Fund reduced Gather observations on ownership, HIV grants and the indicators used for Phasing out of top-up financing or alignment, and the Global Fund from key routine reporting for HIV/AIDS financial incentives in projects by external Linkage between Global Fund HIV grant Appendix O 114 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I stakeholders reporting and the national health and agencies finance reporting? A. Alignment between Global Fund HIV Grant auditing and the national auditing system? B. What is the extent of alignment between the Global Fund HIV grant procurement system and the national procurement system? To what extent are the following processes Extent of use of country public financial country led? How can country involvement management system – percent of donor be increased with respect to: partners that use country’s system. Prioritizing interventions and activities, Evidence of a reform program in this area grant proposal development, budget that will improve quality of public financial development, work plan development, management system grant implementation and oversight, selecting indicators for M&E, and reporting Strengthened capacity by coordinated support — Percent of donor capacity- development support provided through coordinated programs consistent with national development strategies Existence of enabling factors in country to Identify measures, if any, to improve Enabling factors in the country that allow allow for alignment by external partners alignment between Global Fund grant and for alignment by external partners Are there existing collaborative country systems For example: Operational development mechanisms to be leveraged? strategies that have clear strategic priorities linked to a medium-term expenditure framework. Reliable country systems 115 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I C. Harmonization Harmonization efforts are also reported The extent to which Global Fund planning, Extent to which external partners are Use of common arrangements or under other sections implementation, and reporting processes harmonizing their AIDS administrative and procedures – and other common This section will look at evidence of are harmonized with other donors’ reporting mechanisms arrangement and procedures, for harmonization on any issue requirements (with implications for Extent to which they are harmonizing their example, SWAps reducing transaction costs of receiving AIDS technical assistance strategies Global Fund grants) Note: Under this topic, harmonization, the CPA also sought information on the “additionality� of Global Fund assistance. It attempted to gather information on total number of donors and the share of funding provided, pre- and post- Global Fund grants, for each of the three diseases: e.g. changes in level of funding by each donor over time, whether any donors dropped out; and overall level of funding over time. Harmonization of planning and Assess the aggregate effects of the Global implementation procedures by different Fund on overall funding for the three diseases; donors within the sector in question the degree of harmonization with other donors’ planning and implementation procedures; how well the Global Fund contributes to and adapts to support harmonization and the “Three Ones�; and whether the Global Fund has opportunity to improve donor harmonization at the country level Functioning collaborative mechanisms How does the CCM relate to other donor Evidence of shared analytics —Joint that already exist in-country that can be coordination mechanisms in country? donor missions and country analytic tapped or piggy-backed on. For example: work—(diagnostic work too)?  Technical working groups in Health and HIV  Joint donor missions and diagnostic work Appendix O 116 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I D. Finances, Financial Management, and Resource Mobilization Evidence of pooled funding, The CPA did not talk about pooled Looked for pool funding SWAp or basket funding SWAps financing because the Global Fund had Move to budget support, SWAp, or not decided if it would support this. Pooled basket funding funding is neither addressed in the CPA Scaling up the SWAp beyond the nor in Study Area 2. pioneering sectors (education and health) Mobilization of local/national resources CPA narrowly focused on mobilizing Tap private sector resource mobilization private sector financing (an operational principle of Global Fund model) at the country level This is a lagging performance indicator. CPA focused on strength of local CCM strategy in mobilizing private money What are the attempts and constraints toward identifying and mapping out potential private sector donors in-country What are constraints—are they due to lack of clarity of roles of partners on the ground, CCM, Principal Recipient, sub- recipient, or LFA to undertake resource mobilization? CPA also addressed perceived urgency of CCM partners about this issue Predictable and untied aid Multiyear, more than three years of Untied aid funding (aid predictability) Predictability of aid Public financial management systems Use of country public financial management systems and evidence of reform program to achieve this At country level, phase out top-up financing or financial incentives for public sector workers 117 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I Aid flows—where are they going and how External aid reflected in national budgets Aid flows are aligned with national are they reflected in the national budget? and medium-term expenditure framework priorities. How are direct flows to CSOs accounted Percent of aid flows to the government for in national accounting? sector that is reported /reflected on partners’ national budgets Percent of aid flow directly to CSO Additionality of aid by the program in CPA addressed “additionality� of Global question if new to country Fund assistance. It attempted to gather (This is a useful performance indicator to information on total number of donors and monitor) the share of funding provided, pre- and post- Global Fund grants, for each of the three diseases; e.g., changes in level of funding by each donor over time, whether any donors dropped out, and overall level of funding over time. E. Managing for Results M&E UNAIDS supports the country’s national Evidence of managing for results AIDS M&E system—CHAT does not look for evidence of M&E on the assumption it exists Evidence of building country institutional Global Fund assists countries by Evidence of a transparent and capacity for M&E developing tools and processes to monitor monitorable performance assessment performance and respond to gaps (M&E framework and of building institutional toolkit, scorecards, phase 2 processes, capacity by donor program to apply it EARS). Use of PBF Unlike UNAIDS and the Paris Declaration, Use of results-oriented performance the CPA is highly focused on assessing assessment framework the appropriateness of the design and Evidence of transparent and monitorable functioning of the PBF system and how it performance assessment frameworks can be improved that allow for assessing progress against national development strategies and against sector programs Appendix O 118 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I Assess impact (positive and negative) of Assess how has the Global Fund model of M&E system introduced by program into PBF changed the way the national disease the country as requirement for program (HIV/AIDS, tuberculosis or participation malaria) operates CPA assessed capability of local implementing agencies to meet the requirements of PBF in the grant implementation. Is there greater accountability and efficiency in providing health services as a result of the PBF system. CPA also looked at details of identifying indicators and how inclusive it is in the process. Use of country management information Looks at linkages between Global Fund Use of country management information Evidence of attempts to establish systems M&E and the country health management systems and linkages between sectors and the information systems extent of alignment of partners’ M&E for National Integrated M&E Strategy (this AIDS with the national AIDS M&E system includes elaboration of a national strategy for capacity building of M&E systems, which donors would be invited to support through programmatic aid) Joint annual reviews Extent of joint annual reviews with Shared country analytics including joint government and other development assessments partner agencies; Agreement on analytical tools Agreement on analytical tools and use of Joint conduct and use of core diagnostic and use of shared approaches and shared approaches and instruments reviews (Country Financial Accountability instruments Assessments, Public Expenditure Reviews, Country Procurement Assessment Reviews) 119 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I F. Procurement and Supply Management Harmonization of procurement Look for evidence of coordination by Use of country procurement systems – development partners to avoid duplication and evidence of reform program in of procurement? procurement supply management (PSM Which development partner agencies in the country), e.g., decreasing number involved? of donors that do not use country PSM How could coordination and harmonization in procurement be improved? Have there been any procurement audits? Address structural issues of procurement How were forecasts for drugs and and supply management commodities for malaria grants Highly relevant for an investment developed? Tools used? partnership program Assess how forecasts were coordinated with the needs for the whole sector in country? What effects on cost/quality or supply of products? Consistency of application of Global Fund policy on procurement and guidelines (direct payment and multiyear orders) in selection of vendors by Principal Recipient and sub-recipients Assess extent of disbursement delays, stock outs, (what stop-gap measures are used to compensate for stock-outs due to problems with procurement? [e.g., paying suppliers on time]) Existence of diagnostics to assess structural problems with procurement — and extent to which problem is being solved by procurement practices Extent of partners out-sourcing Appendix O 120 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I procurement to another organization besides the Principal Recipient Extent to which all partners investing in any one commodity— e.g., HIV or tuberculosis drugs using one procurement approach and one supplier to leverage negotiation of reduced prices and economy of scale Routine review of country-level Conduct sample of tender analysis (not procurement activities—quality and procurement audit) compliance Routine review and assessment of service delivery level of sub-recipient’s procurement supply management (PSM) and financial management capacity in cases where sub-recipients routinely undertake substantial PSM functions; and in countries where Principal Recipients are financial pass-throughs, and not implementation agencies Routine monitoring of disbursement and/or procurement delays to sub-recipients. Track and monitor chain of inputs to outputs Assessment of sub-recipient’s PSM and financial management capacity prior to grant approvals. Procurement auditing Number and frequency of procurement audits. Extent to which country partners coordinate procurement and/or collectively negotiate commodity (drug) prices with suppliers 121 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I No signs that local producers and suppliers are crowded out by procurement practices of large international programs G. Capacity Building / Technical Assistance Examine Issues around need for technical assistance to first build up the country processes, institutions, and systems, in order that use of country systems (for alignment) can take place How effectively has the program done this? Quality, relevance, and usefulness of Extent to which Global Fund grants and Relevance, effectiveness, and scope of Strengthen capacity by coordinated technical assistance provided by other development partner agencies have capacity building efforts of partners to support — percent of donor capacity- partnership program increased local capacity national AIDS M&E response development support provided through Have the PBF requirements increased coordinated programs consistent with capacity at the local level? Have Principal national development strategies Recipients or sub-recipients received training in M&E, financial management, or procurement? Have sub-recipients and Principal Recipients (implementers) changed the way that they perform their functions because of the Global Fund PBF system? Assess usefulness and effectiveness of technical assistance recommendations? How well do technical assistance systems of different donors function? Country-led technical assistance plans Are technical assistance funds from the Country led technical assistance plans Demand-driven approach to capacity grant budgets used regularly? Demand-driven approach to capacity building building Appendix O 122 Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I Adequacy of external funding for Is there enough funding for technical Evidence of adequate funding by external technical assistance assistance? partners for technical assistance Is funding readily accessible? Guidelines and ease with which to access Usefulness and adequacy of Global Fund technical assistance guidelines to CCM and Principal Recipient on procuring technical assistance? a. If guidelines exist, were they used? Did guidelines require a competitive technical assistance procurement process? Which partners have been key in facilitating the technical assistance process, and in what ways? Harmonization and alignment of technical Can partners’ roles and responsibilities in Extent of alignment of partners’ M&E for Comprehensive capacity building plans assistance by donors technical assistance be clarified or AIDS with the national AIDS M&E system that are harmonized and aligned with coordinated better? national needs and strategy. What obstacles, if any, affect the ability of Evidence of strengthened capacity by Global Fund partners to identify technical coordinated support — Percent of donor assistance needs and coordinate capacity-development support provided requests? through coordinated programs consistent with partners’ national development strategies How might technical assistance be How could technical assistance be improved? improved How might Global Fund Secretariat, CCM, LFA, Principal Recipient, sub-recipient, and development-partner agencies overcome technical assistance issues ? 123 Appendix O Instruments Reviewed Global Fund Evaluation UNAIDS Country Partnership Country Harmonization Paris Declaration Evaluation Criteria/Topics Assessment (CPA) Assessment Tool (CHAT) Phase I H. Accountability Issues of reporting, communications, Extent of alignment between Global Fund Extent to which international partners are mutual accountability. grants and Ministry of Health planning harmonizing financial reporting with each Reflection of official development cycles (annual or biannual); alignment other and in relation to the AIDS response. assistance in national budget between Global Fund grants and What sort of barriers/bottlenecks exist indicators used for routine reporting for limiting timely information flows to tuberculosis, HIV, and malaria; and grant marginalized groups? reporting with the national health reporting and with national financial reporting requirements Openness and transparency Extent of openness and transparency Publish timely, transparent, and reliable among national partners and the NAC reports on budget planning and execution that meet INTOSAI (International Organization of Supreme Audit Institutions) standards Accountability Has alignment of Global Fund grants with national HIV/AIDS programs increased accountability by country clients? Mutual accountability Extent of transparent, timely, and accurate Mutual accountability communications among international Donors provide timely, transparent, and organizations and with all members of the comprehensive information on aid flows NAC and program intentions to government Information flows significantly improved through the national M&E system for official development assistance Indicator 12 (mutual assessment of progress) Mutual accountability — Number of partner countries that undertake mutual assessments of progress in implementing agreed commitments on aid effectiveness including those in this Declaration Appendix P 124 Appendix P. Quality Review of Study Area 3 of the Five- Year Evaluation 1. This quality review is concerned with one component of the FYE framework: Study Area 3 on Impact Evaluation. In October 2003, the Global Fund Board approved a five-year evaluation of the Global Fund’s overall performance in terms of its organizational efficiency, success of country partnership systems, and overall impact. Study Area 3 concerns itself with the impact question. The Study Area 3 approach has been to examine collective efforts, including those of other major agencies and programs, and describe their contribution to the overall reduction in burden of these three diseases. Eighteen countries were considered under Study Area 3, of which eight countries had primary data collection activities, while in ten countries, impact evaluation was based on secondary sources. This quality review focuses on the design of the Impact Evaluation of the Global Fund, not its implementation process. An implementation process that is guided by and adheres to sound principles of evaluation management, coordination, partnership building, and capacity strengthening is indeed necessary, but it is not sufficient to ensure the relevance and credibility of inferences made by the evaluation. This is not to say that implementation process aspects are completely ignored in this review, but help frame the discussion around the quality of the Global Fund Impact Evaluation design. Defining Impact Evaluation 2. Impact evaluation is the counterfactual analysis of the impact of an intervention on final welfare outcomes (IEG, nd) .21 According to NONIE, the two underlying premises for impact evaluation are attribution and counterfactual. Asian Development Bank guidelines say: “Impact evaluation establishes whether the intervention had a welfare effect on individuals, households, and communities, and whether this effect can be attributed to the concerned intervention.� The Center for Global Development posits “Impact evaluation asks about the difference between what happened with the program and what would have happened without it (referred to as the counterfactual).�22 The draft chapter on evaluation in the U.N. Management Handbook states that: “IE tries to measure…causal effect…The impact of a program is the difference between beneficiaries’ well-being after the program and some benefit of beneficiaries’ well-being had there been no program.� According to International Initiative for Impact Evaluation (3IE), “high quality impact evaluations measure the net change in outcomes that can be attributed to a specific program.� Based on these statements, the defining characteristic of an impact evaluation is its focus on attribution. 3. Most of the current debate on design and methodological aspects of impact evaluation centers on resolving the attribution problem. This can be accomplished using several methodologies, which fall into two broad categories: experimental designs 21. For example, DIME says “Impact evaluations assess the specific outcomes attributable to particular intervention or program. They do so by comparing outcomes where the intervention is applied against outcomes where the intervention does not exist.� Ravaillon (2008) states: “An impact evaluation aims to assess a program’s performance against an explicit counterfactual, such as the situation in the absence of the program.� 22. Indeed, this was the definition which was intended in the report of the Centre for Global Development, “When Will We Ever Learn?� 125 Appendix P (randomized) and quasi-experimental designs (nonrandomized). Each of these methods carries its own assumptions about the nature of potential selection bias in program targeting and participation, and these assumptions are crucial to developing the appropriate model to determine program impacts. 4. However, for an impact evaluation to have better policy and operational relevance, it is important to understand not just what works, but why. A theory-based impact evaluation design is one in which the analysis is conducted along the length of the causal chain from inputs to impacts, and goes beyond what worked to understand why a program has, or has not, had an impact. White (2009) outlines six key principles of a theory-based impact evaluation,23 one of which is construction of a comparison group using experimental or quasi-experimental methods- for rigorous evaluation of impact. The evaluation of the Bangladesh Integrated Nutrition Program is an example of a theory-based evaluation. Design of Global Fund Impact Evaluation 5. The Study Area 3 evaluation design follows a step-wise approach. The step-wise approach (Figure 1) consists of four sequentially linked questions on trends in funding, access to services, coverage of interventions and risk behaviors, and health outcomes. Within the limits set by contextual factors, improvements at each step are expected to be plausibly ascribed to improvements in the previous step. 6. Given that attribution is the defining characteristic of an impact evaluation, the evaluation study for Study Area 3 is not an impact evaluation. One of the criteria for a quality impact evaluation leads from the attribution premise.24 However, the Study Area 3 evaluation study does not meet this criterion, and it did not set out to do so. From the outset, the Study Area 3 evaluation report says that “the impact evaluation sets out to assess overall impact on the three diseases and the contributions of the Global Fund without direct attribution,� and goes on to describe the report as an “adequacy evaluation.�25 Although not an impact evaluation, an evaluation study of this type is very useful. According to Victora et al. (2010), such approaches, especially in the early years of implementation, can be telling about the quality of targeting; whether implementation is strong enough to generate impact; and of the multiplicity of delivery methods available, which approaches are likely to rapidly increase coverage in the short-term. 23. Map out the causal chain (program theory); understand context; anticipate heterogeneity; rigorous evaluation of impact using a credible counterfactual; rigorous factual analysis; use mixed methods. 24. “Develop a logically sound counterfactual presenting a plausible argument that observed changes in outcome indicators after the project intervention are in fact due to the project and not to other unrelated factors, such as improvements in local economies or other programs� (IEG 2006). 25. Adequacy evaluations are limited to describing if expected changes have occurred, and are unable to causally link program activities to observed changes (Habicht et al. 1999). By contrast, probability and plausibility evaluations correspond to experimental and quasi-experimental design, respectively. Appendix P 126 Figure P-1. Study Area 3 Evaluation Design: Step-Wise Framework INPUTS ACTIVITIES OUTPUTS OUTCOMES IMPACTS Other International Training & resources capacity building Health services Morbidity Intervention Procurement & Delivery & Global Fund coverage supply quality Mortality resources Behavioral Guidelines Behavioral Disease coverage IEC interventions & consequences Domestic Community knowledge resources mobilization CONTEXTUAL FACTORS Has funding Has access and Has coverage Have health increased? quality of improved and outcomes How much? services risk behavior improved? What sources? improved? changed? Source: Constructed/adapted by IEG from Technical Background Paper, Synthesis Report, and Study Area 3. Note: IEC = information, education, and communication Assessing Quality of Evaluation Design 7. Rigorous impact evaluations are resource-, time-, and data-intensive, and not all programs are amenable to an impact evaluation. Program managers may decide if it is feasible to carry out an impact evaluation on the basis of some of the following criteria: (1) timing, (2) plausible counterfactual, (3) data availability. Any quality review of the Study Area 3 evaluation study must therefore begin by addressing the relevance of the evaluation approach against the feasibility criteria, keeping in mind the challenges that may impede/facilitate choice of evaluation strategy.  Timing: Evaluations are subject to the implementation time frame of the program. Even when projects move forward at the established pace, some interventions take longer to implement, such as infrastructure, and some take longer to manifest themselves in the beneficiary population (Baker 2000). In the case of the Global Fund, the timing of the Study Area 3 evaluation — especially as it pertains to behavioral change and impact levels of the step-wise framework, and irrespective of the design strategy it could have pursued — was premature. Scaling up through the Global Fund, PEPFAR, and other disbursements began in 2003, but only reached a substantial level of funding and number of countries in 2004–05. The time between a Board decision on a proposal and actual implementation can easily reach 15–23 127 Appendix P months,26 while the time between implementation and interventions and reaching high coverage levels, to subsequent population impact, can take an additional few months (e.g., treatment) to several years (e.g., behavior change program). Considering that the evaluation period is 2003–07, the pace of implementation makes it almost impossible to document the full health impact. The advantage of the Study Area 3 evaluation approach in the face of the timing constraint is that, at least for earlier steps in the results chain, the study can document the effects of collective scaling-up efforts with some certainty.  Plausible Counterfactual: As mentioned before, impact evaluations require a comparison group that did not receive the treatment. Collective scaling-up efforts in this context were intended to treat the whole of eligible population and were intended to be countrywide. This makes identifying a counterfactual a very difficult task. The response of Study Area 3 to this problem has been the forfeiting of any claim to attribution in favor of a step-wise framework and reflexive (before vs. after) comparison. Reflexive comparisons are, of course, useful in that they can tell if expected changes have occurred, but this does not mean that the program in question caused this change. A cautionary tale in this respect is that of Bangladesh Integrated Nutrition Project (BINP), a growth-monitoring project, where factual analysis and counterfactual analysis produced contradictory results. Although it may appear impossible to do an impact evaluation of complex and large- scale efforts such as the Global Fund, researchers have used creative strategies to construct plausible counterfactuals when one was not easily identified. Duflo (2001) examined the effect of a large-scale school construction program in Indonesia on educational attainment and wages by exploiting regional differences in program intensity and differences in exposure across cohorts induced by the timing of the program. Osili and Long (2007) exploited regional variations in intensity of funding received to examine if introduction of universal primary education caused discontinuities in educational attainment and early fertility. Galasso and Ravallion (2004) evaluated a large social protection program in Argentina, Jefes y Jefas, which was created by the government in response to the 2001 financial crisis. The program was scaling up rapidly, and comparison units were therefore constructed from a subset of applicants who were not yet part of the program. Participants were matched to comparison observations on the basis of propensity-score matching methods. Piehl et al. (2003) used observed outcomes for participants over several years to test for structural changes in outcomes (Ravallion 2008). Having said this, in the case of Study Area 3, these approaches may have been plausible in some of the study countries (in the absence of implementation information, we cannot say if it was or was not doable). Considering the time constraint under which data collection and analysis took place, it may have impinged on a careful examination of data to see if some kind of counterfactual analysis was plausible.  Data Availability & Quality: The Study Area 3 report points to major data gaps and weak health information systems, impinging on the quality and availability of 26. Lag of approximately 9–12 months between Board approval and grant signing, 2–3 months between grant signing and disbursement, and between 4–8 months between disbursements and implementation in country. Appendix P 128 relevant data. For instance, baseline data was largely missing; there was lack of data on AIDS morality; there was a long lag time between data collection and availability of results; there was inadequate data on antiretroviral treatment adherence and survival; there was poor-quality data on provision of interventions; there was fragmented information flow; there was incomplete and inaccurate data on community interventions, and so on. Under Study Area 3, data collection efforts were undertaken to bridge some data gaps, but there is still room for improvement. Given the problems with completeness, reliability, and consistency of data, impact evaluations may not be very feasible for all countries, because these require good- quality data. However, the Study Area 3 design has a less rigid approach (for instance, intervention data and outcome data are not always provided for the same period), which makes it a more feasible design in this context. 8. To summarize, given the data and timing constraints, the step-wise framework is feasible as an evaluation tool, although in instances where data is complete and reliable, where pace and/or coverage of scaling-up offers the opportunity to construct a plausible counterfactual, and where sufficient time seems to have passed to generate outcomes, an impact evaluation may be feasible. Assessing Quality of Evaluation Design—Contribution Analysis 9. The Study Area 3 report is not an impact evaluation, nor is it intended to be. Since the evaluation question is to assess the reduction of overall disease burden, and the contribution of the Global Fund, a different analytical framework, rather than one that applies to impact evaluation, must be used to assess the quality of the Study Area 3 evaluation design. In this context, contribution analysis is one such analytical framework against which the quality of the Study Area 3 design can be assessed. Contribution analysis is defined as “a specific analysis undertaken to provide information on the contribution of a program to the outcomes it is trying to influence� (Mayne 1999). It aims at "finding credible ways of demonstrating that you have made a difference through your actions and efforts to the outcomes� (AusAID 2004). The broader approach to contribution analysis attempts to describe what Hendricks (1996) calls a "plausible association"; where a reasonable person, knowing what has occurred/is occurring in the program, agrees that the program contributed/is contributing to the outcomes. It does not prove a contribution, but provides evidence to reduce the uncertainty about the contribution made (Mayne 1999). 10. Next, we assess the extent to which the evaluation study puts forward a credible contribution analysis story. For a performance story to be credible, Mayne proposes that a good quality contribution analysis should set out the program context (including the results chain), planned and actual accomplishments, lessons learnt, and the main alternative explanations for the outcomes occurring and show why they had no or limited influence. We found the Study Area 3 study design framework represented by a step-wise/logic model (Figure P-1) to be robust conceptually, in that the model demonstrates plausible and logical links across all levels from activity through intermediate to end outcomes, and highlights the role of contextual factors in affecting outcomes. However:  Not all the assumptions behind the Study Area 3 logic model are either explicated or tested in the study. To the extent that assumptions are spelled out, these can be found 129 Appendix P scattered throughout the document and rarely justified. To name a few, the evaluation assumes that (i): In the absence of scaling up efforts, mortality and morbidity due to the three diseases and intervention coverage would have at best remained the same or worsened; (ii) Expected expenditure is flat-lined from 2003 to 2006. These are fairly strong assumptions yet they are not fully addressed. For instance, in Cambodia, national expansion of DOTs was underway since early 2000s reaching completion in 2004. So, under assumption (i), tuberculosis disease burden and coverage in Cambodia would have remained unchanged even worsened which is hard to believe. We cannot also discount lagged effects. For instance, since prevention programs take time to generate outcomes and impact, it is plausible that in some countries, it is not collective efforts since 2003 but prevention initiatives pre-dating the Fund that could have influenced outcomes. This is again a violation of assumption (i).  A missing link in the step-wise approach is the absence of implementation quality information, even though the FYE sees it as an important determinant of impact. Collective efforts represent a complex situation with multiple interventions, each of which interact with each other to influence final outcomes, and are implemented under by multiple agents with their own strengths and weaknesses. The operational issues that arise from the complexity of efforts being evaluated may influence outcomes and were not addressed in Study Area 3. Although Study Area 1 and Study Area 2 address these issues for the Global Fund, there was no information collected on implementation quality of other major funders. Notwithstanding this, linking analysis in Study Area 3 with findings from Study Area 1 and Study Area 2 in the context of the Global Fund would have at least helped understand better the contribution of the Global Fund. Even from the overall evaluation framework of the Global Fund FYE, it is evident that Study Area , Study Area 2 and Study Area 3 were seen as sequential and interlinked. To the extent that concurrent timing of the three evaluations is responsible for this, a clear lesson for the future is to afford enough time to incorporate lessons from different but linked evaluations.  Little information was presented on evidence behind external factors that may influence outcomes. For instance, Boerma et al. (2010) points to changes in socioeconomic welfare, transport and communications, weather conditions, secular changes in disease burden, as well as cyclical patterns in other disease, migratory patterns, etc as factors that influence outcome indicators in the context of these diseases. Although the design framework posits he importance of contextual factors, the actual study makes little effort to integrate evidence of this inn interpreting the contribution of collective efforts. This does not always require additional data collection; there may be existing research available and even if no such studies are available, effort should have been made to make a case there were or not any new initiatives or trends that could have potentially contributed to reducing the disease burden.  Although data constraints compel looking at outcome/impact level indicators from a “collective efforts� perspective, this is ultimately a Global Fund evaluation. We found that there was little attention to analyzing outcome patterns vis-à-vis intensity of Global Fund contribution, for example, how expected changes trended in countries where the Global Fund was actively involved compared to countries where it was the Appendix P 130 dominant financier. This is important because different funders employ different delivery modalities, and any lessons on what works better and where may be operationally useful for the Global Fund and improve the collective performance story. 11. To summarize, the design of Study Area 3 study was sound enough to assess the contribution of Collective Efforts to reducing the disease burden; however, the weaknesses has more to do with the execution of the evaluation design, not its concept. Some, if not all, of these weaknesses could be explained by data and timing constraints. Lessons:  The timing of an evaluation is an important determinant of the quality of evaluation and the credibility of analysis. Especially where evaluation focuses on impacts, it is important that enough time has passed for program interventions to translate into impact.  Explore possibilities for doing impact evaluation in specific cases where it may be feasible to do so. For instance, in countries where implementation has been phased or there is non-universal coverage, creation of a counterfactual may be plausible. Also relevant is the quality and availability of data, so countries where data is missing or quality is questionable, an Impact Evaluation will not be feasible.  Any theory of change/program logic that forms the basis of inferring program results is as good as the assumptions underlying it. Going forward, successive evaluation efforts should carefully assess the assumptions behind the program logic, as well as the risks, to strengthen the contribution story. The role of external factors in influencing outcomes must be incorporated in future evaluations. If the assumption is that no external factors are significant determinants, then this assumption needs to be justified.  The data collected under Study Area 3 provides a good starting point for future rounds of evaluations. Going forward in the future, there is a need to sustain these data collection efforts, and bridge more crucial data gaps.  Since this is an evaluation intended to improve performance of the Global Fund, it is important that more attention is paid to analyzing the contribution of the Global Fund to changes in outcomes. A better understanding of how outcomes trend in countries where the Global Fund is a minority player versus where it is the majority financier is useful and can lead to more efficient use of resources. Related to this is the need for more coherence between operational and impact assessments. For instance, Study Area 1 and Study Area 2 were intended to be linked with Study Area 3 in a sequential evaluation framework, yet Study Area 3 was not able to use findings from Study Area 1 and Study Area 2 in informing the analysis. 131 Appendix Q Appendix Q. Results of the Electronic Survey of World Bank Task Team Leaders and Global Fund Secretariat Staff This electronic survey, which was administered to the staff of both organizations in March 2011, sought their views on the breadth of the engagement between the two organizations since the Global Fund was established in 2002. In the case of the World Bank, the survey was sent to all the task team leaders (project managers) of Bank-supported health projects that were disbursing when, or approved after, the Global Fund became active in the same country (the date of its first grant commitment to the country). At least one of the designated themes of their projects was HIV/AIDS, tuberculosis, malaria, communicable diseases, or health system performance. In the case of the Global Fund, the survey was sent to Secretariat staff in the Country Programs Cluster, the External Relations and Partnerships Cluster, and the Strategy, Performance and Evaluation Cluster. IEG gratefully acknowledges the assistance of Oren Ginzburg, Sandii Lwin, and Igor Oliynyk in administering the survey to Global Fund staff. This appendix presents, in tabular and graphic form, only the responses to the closed-ended questions in the survey. The complete results, including the responses to open-ended questions, will be available on the Web site at www.globalevaluations.org. Most of the questions in the two surveys were identical in order to compare the responses of the staff in the two organizations. Four questions were necessarily different, but still similar in nature. (See questions 6, 10, 11, and 12 below.) This survey was confidential. The responses are presented in aggregate form, making it impossible to identify individual responses. Background Questions to World Bank Task Team Leaders (TTLs) Question 1. Please indicate the countries in which you have been the TTL of record for a Bank-supported health project that was disbursing at the same time that the Global Fund was also active in the same country. If you identified more than one country, please answer this survey from the point of view of the country on which you worked the longest on a health project and in which the Global Fund has been the most active. World Bank TTL Respondents by Region Region Number of Respondents Share of Respondents Africa 20 48% East Asia & Pacific 6 14% Latin America & Caribbean 6 14% South Asia 5 12% Europe & Central Asia 4 10% Middle East & North Africa 1 2% Total 42 /1 100% /1 This represents a response rate of 33 percent (42 of 128). Appendix Q 132 Question 2. During the time period for which you were the TTL for the country you selected, please indicate where you were based. Number of TTL Location Respondents Share of Respondents In the World Bank office in the country 21 54% At World Bank Headquarters in Washington, DC 15 38% In the World Bank office in a neighboring country 3 8% Total 39 100% Question 3. Please indicate your professional background. Professional background Number of Respondents Share of Respondents Health, nutrition, or population specialist 24 62% Operations officer 7 18% Health economist 5 13% Other (please specify) 3 8% Total 39 100% Question 4. To what extent are you familiar with elements of the Global Fund’s current reform agenda such as the new grant architecture and grant consolidation process, National Strategy Applications, and the Country Team Approach? Level of familiarity Number of Respondents Share of Respondents A great deal 2 5% Substantially 9 23% Somewhat 16 41% Not at all 12 31% Total 39 100% 133 Appendix Q Background Questions to Global Fund Secretariat Staff Question 1. Please indicate the Cluster in which you are working. Number of Cluster Respondents Share of Respondents a Country Programs Cluster 36 69% Strategy, Performance and Evaluation Cluster 9 17% External Relations and Partnerships Cluster 7 13% b Total 52 100% a. This represents a response rate of 62 percent (36 of 58) for those questions that were only addressed to the Country Program Cluster. b. This represents an overall response rate of 49 percent (52 of 106) for the questions that were addressed to all three Clusters. Question 2. Please indicate the geographical area for which you are answering this survey. If you are a Fund Portfolio Manager that has worked on more than one country, please answer these questions from the point of view of the country on which you have worked the longest and in which the Global Fund has been most active. Country Programs Cluster Respondents by Region Region Number of Respondents Share of Respondents Africa 14 39% East Asia & Pacific 7 19% Latin America & Caribbean 5 14% South Asia 5 14% Europe & Central Asia 2 6% Middle East & North Africa 2 6% Global 1 3% Total 36 100% Question 3. Please indicate your professional background. Professional background Number of Respondents Share of Respondents Public health 18 38% Business administration 11 23% Medicine 3 6% Financial management 1 2% Accounting 1 2% Other (please specify) 14 29% Total 48 100% Appendix Q 134 Questions Addressed to World Bank TTLs and Global Fund Country Programs Cluster Only Question 4. In which of the following country-level processes of the Global Fund did World Bank staff or consultants participate during the years that you were working on this country? (Sorted in descending order: See Figure 1.) Responses by Organization Yes No Don’t Know Total Q4a: Member of the Country Coordinating Mechanism (CCM): World Bank Task Team Leader 12 23 7 42 Global Fund – Country Programs Cluster 13 21 2 36 Q4g: Providing formal technical assistance to the Principal Recipients of Global Fund grants: World Bank Task Team Leaders 9 28 5 42 Global Fund – Country Programs Cluster 10 19 7 36 Q4b: Helping to prepare grant proposals for submission to the Global Fund: World Bank Task Team Leaders 11 27 4 42 Global Fund – Country Programs Cluster 9 20 7 36 Q4f: Helping with the oversight/supervision of Global Fund-financed activities: World Bank Task Team Leaders 8 30 4 42 Global Fund – Country Programs Cluster 8 19 9 36 Q4d: Helping to select Principal Recipients to implement approved Global Fund grants: World Bank Task Team Leaders 3 34 5 42 Global Fund – Country Programs Cluster 8 22 6 36 Q4e: Helping with financial management/procurement of Global Fund-financed activities: World Bank Task Team Leaders 4 34 4 42 Global Fund – Country Programs Cluster 7 23 6 36 Q4c: Participating in the selection of grant proposals for submission from the CCM to the Global Fund: World Bank Task Team Leaders 7 30 5 42 Global Fund – Country Programs Cluster 5 19 12 36 Question 5. In what other ways were World Bank staff or consultants involved in country- level activities that directly or indirectly contributed to the work of the Global Fund during the years that you have been working on this region, subregion, or country? (Sorted in descending order: See Figure 2.) Responses by Organization Yes No Don’t Know Total Q5c: Supporting ANALYTICAL WORK in relation to STRENGTHENING HEALTH SYSTEMS: World Bank Task Team Leaders 25 13 4 42 Global Fund – Country Programs Cluster 22 3 11 36 Q5a: Helping to prepare COUNTRY STRATEGIES such as an AIDS Strategy and Action Plan (ASAP) for combating HIV/AIDS, or malaria: World Bank Task Team Leaders 26 12 4 42 Global Fund – Country Programs Cluster 21 5 10 36 Q5b: Supporting ANALYTICAL WORK in relation to COMBATING HIV/AIDS, , or MALARIA: World Bank Task Team Leaders 19 18 4 41 Global Fund – Country Programs Cluster 16 7 13 36 Q5d: Helping to BUILD HUMAN RESOURCE CAPACITY to prepare and implement Global Fund grants in the country: World Bank Task Team Leaders 18 20 4 42 Global Fund – Country Programs Cluster 10 11 15 36 135 Appendix Q Figure 1. In which of the following country-level processes of the Global Fund did World Bank staff or consultants participate during the years that you were working on this country? (Percent “Yes�) Member of the Country Coordinating Mechanism Providing formal technical assistance to the Principal Recipients of Global Fund grants Helping to prepare grant proposals for submission to the Global Fund Helping with the oversight/supervision of Global Fund–financed activities Helping to select Principal Recipients to implement approved Global Fund grants Helping with financial management/procurement of Global Fund-financed activities Participating in the selection of grant proposals for submission from the CCM to the Global Fund 0% 10% 20% 30% 40% GF � Country Programs Staff WB � Task  Team Leaders Appendix Q 136 Figure 2. In what other ways were World Bank staff or consultants involved in country- level activities that directly or indirectly contributed to the work of the Global Fund during the years that you were working on this country? (Percent “Yes�) Supporting analytical work in relation to strengthening health systems Helping to prepare country strategies such as an AIDS Strategy and Action Plan (ASAP) for combating HIV/AIDS, tuberculosis, or malaria Supporting analytical work in relation to combating HIV/AIDS, tuberculosis, or malaria Helping to build human resource capacity to prepare and implement Global Fund grants in the country 0% 20% 40% 60% 80% 100% GF � Country Programs Staff WB � Task  Team Leaders 137 Appendix Q Question 6 (to World Bank TTLs). Which of the following managers/staff/agents of the Global Fund did you contact and work with during the years that you were working on this country? (Sorted in descending order. See Figure 3.) Don’t Responses Regularly Occasionally Not at all Total Know Q6d: Principal Recipients of Global Fund grants, in 12 12 18 0 42 their role as Principal Recipients: Q6c: The Country Coordinating Mechanism (CCM): 11 10 21 0 42 Q6b: The Fund Portfolio Manager (FPM), based at 3 17 21 1 42 the Global Fund Secretariat in Geneva: Q6a: The Global Fund Country Team Leader, based 4 13 24 1 42 at the Global Fund Secretariat in Geneva: Q6e: The Local Fund Agent 3 13 25 1 42 Question 6 (to Global Fund Country Programs Cluster). Which of the following managers and staff of the World Bank did you contact and work with during the years that you have been working on this region, subregion, or country? (Sorted in descending order. See Figure 4.) Don’t Responses Regularly Occasionally Not at all Total Know Q6b: The Task Team Leader (TTL) of World Bank- 7 13 14 2 36 supported projects in the country: Q6c: The Project Implementation Units of World 2 15 17 2 36 Bank-supported health projects in the country: Q6e: Lead Human Development Specialists or 6 4 21 5 36 Economists: Q6d: The Regional Sector Manager for Health, 3 7 22 4 36 Nutrition and Population: Q6a: The Country Director for the country on which 1 9 22 4 36 you were working: Appendix Q 138 Figure 3. World Bank Task Team Leaders: Which of the following managers/staff/ agents of the Global Fund did you contact and work with during the years that you were working on this country? Principal Recipients of Global Fund grants, in their role as Principal Recipients The Country Coordinating Mechanism (CCM) The Fund Portfolio Manager (FPM), based at the Global Fund Secretariat in Geneva The Global Fund Country Team Leader, based at the Global Fund Secretariat in Geneva The Local Fund Agent 0% 20% 40% 60% 80% 100% Regularly Occasionally Not at all Figure 4. Global Fund – Country Programs Cluster: Which of the following managers and staff of the World Bank did you contact and work with during the years that you have been working on this region, subregion, or country? The Task Team Leader of World Bank-supported projects in the country The Project Implementation Units of World Bank- supported health projects in the country Lead Human Development Specialists or Economists The Regional Sector Manager for Health, Nutrition and Population The Country Director for the country on which you were working 0% 20% 40% 60% 80% 100% Regularly Occasionally Not at all 139 Appendix Q Question 7. Overall, how would you best characterize the relationship between the World Bank and the Global Fund during the years that you were working on this country? (Choose only one.) Responses by Organization Global Fund – Country World Bank TTLs Programs Cluster Collaborative: The two organizations' staff, consultants and agents worked together on common activities in the pursuit of commonly 2 6 agreed objectives. Complementary: The two organizations' staff, consultants, and agents 9 5 worked alongside each other in the pursuit of common objectives. Consultative: The two organizations' staff, consultants, and agents 4 5 consulted each other regularly in the course of their own activities. Sharing information only: The two organizations' staff, consultants, 12 4 and agents only shared information about each other’s activities. Unrelated and independent: The two organizations worked independently of each other supporting different health initiatives in the 8 8 country. Competitive: The two organizations competed for business among the 0 2 same potential clients. Other (Please specify.) 7 6 Total 42 36 Appendix Q 140 Figure 5. Overall, how would you best characterize the relationship between the World Bank and the Global Fund during the years that you were working on this country? Collaborative: The two organizations' staff, consul- tants and agents worked together on common activ- ities in the pursuit of commonly agreed objectives. Complementary: The two organizations' staff, consultants, and agents worked alongside each other in the pursuit of common objectives. Consultative: The two organizations' staff, consultants, and agents consulted each other regularly in the course of their own activities. Sharing information only: The two organizations' staff, consultants, and agents only shared information about each other’s activities. Unrelated and independent: The two organizations worked independently of each other supporting different health initiatives in the country. Competitive: The two organizations competed for business among the same potential clients. 0% 10% 20% 30% 40% GF � Country Programs Staff WB � Task Team Leaders 141 Appendix Q Questions Addressed to World Bank TTLs and All Three Clusters of Global Fund Secretariat Staff Question 8. To what extent do you consider the World Bank to be a partner of the Global Fund AT THE GLOBAL LEVEL? Responses by Organization Negligible Modest Substantial High No Opinion Total World Bank Task Team Leaders 3 19 9 3 5 39 Global Fund – All Clusters 1 11 24 14 0 50 Question 9. To what extent do you consider the World Bank to be a partner of the Global Fund AT THE COUNTRY LEVEL? Responses by Organization Negligible Modest Substantial High No Opinion Total World Bank Task Team Leaders 8 19 9 1 2 39 Global Fund – All Clusters 3 22 15 8 2 50 Figure 6. To what extent do you consider the World Bank to be a partner of the Global Fund (a) at the global level and (b) at the country level? Global Fund – All Clusters: (a) At the Global Level: (b) At the Country Level: World Bank – Task Team Leaders: (a) At the Global Level: (b) At the Country Level 0% 20% 40% 60% 80% 100% High Substantial Modest Negligible Appendix Q 142 Question 10 (to World Bank TTLs): In your opinion, do the following factors make it easier or more difficult for World Bank staff or consultants to engage with Global Fund- supported activities at the country level? Answer all questions on a five-point scale from “much easier� to “much more difficult�. (Sorted in descending order from “much easier� to “much more difficult�. See Figure 7) Neither Some- Some- Much Much easier nor what Response by Sub-question what more Total easier more more easier difficult difficult difficult Q8n: The presence of other mechanisms through which the World Bank and the Global Fund may interact, such as the AIDS Strategy and Action Plans (ASAPs), the Joint Assessment of 5 16 14 4 0 39 National Strategies (JANS), and the Joint Funding Platform for Health Systems Strengthening. Q8d: The focus of the Global Fund on low-income countries 5 11 19 4 0 39 (similar to IDA-eligible countries). Q8i: The presence of civil society organization on the Country Coordinating Mechanism. (CSOs help prepare grant proposals 2 16 17 2 2 39 and may implement some Global Fund-supported activities as Principal Recipients or sub-recipients.) Q8j: The fact that the Principal Recipient (implementing agency) for Global Fund grants is not restricted to government agencies. 2 10 22 5 0 39 (International organizations such as UNDP, CSOs, and universities may be Principal Recipients.) Q8k: The fact that the Local Fund Agent is responsible for overseeing the integrity of the implementation of Global Fund 2 6 23 6 2 39 grants from the Global Fund perspective. Q8b: The success of Global Fund in mobilizing substantial donor resources to combat the three diseases. 2 4 26 7 0 39 Q8c: The fact that the Global Fund provides financial assistance 1 6 22 8 2 39 in the form of grants. Q8a: The absence of written Bank-wide guidelines or directives for engaging with the Global Fund beyond the general language 2 3 21 11 2 39 contained in the 2007 HNP Strategy. Q8l: The fact that Fund Portfolio Managers generally have a different professional background from the Bank’s health sector 1 0 24 12 2 39 task team leaders. Q8h: The fact that Global Fund uses a disease-specific monitoring system to support its performance-based funding 1 2 14 18 4 39 approach to development assistance. Q8g: The different project cycle of the Global Fund compared to the World Bank. (The Country Coordinating Mechanism is responsible for preparing, reviewing and submitting grant 0 0 19 16 4 39 proposals to the Global Fund, and for overseeing implementation from the country perspective.) Q8f: The lack of financial compensation for providing technical support. (This has represented an unfunded mandate.) 0 1 17 17 4 39 Q8m: The absence of a Memorandum of Understanding between the Global Fund and the World Bank for collaborating at the 0 0 13 21 5 39 country level. Q8e: The limited country presence of the Global Fund. (Their Fund Portfolio Managers are based in Geneva.) 0 0 10 14 15 39 143 Appendix Q Figure 7. World Bank Task Team Leaders: In your opinion, do the following factors make it easier or more difficult for World Bank staff or consultants to engage with Global Fund-supported activities at the country level? The presence of other mechanisms through which the World Bank and the Global Fund may interact, such ASAPs, JANS, and the Joint Funding Platform. The focus of the Global Fund on low-income countries (similar to IDA-eligible countries). The presence of civil society organization on the Country Coordinating Mechanism. The fact that the Principal Recipient for Global Fund grants is not restricted to government agencies. The fact that the Local Fund Agent is responsible for overseeing the integrity of the implementation of Global Fund grants from the Global Fund perspective. The success of Global Fund in mobilizing substantial donor resources to combat the three diseases. The fact that the Global Fund provides financial assistance in the form of grants. The absence of written Bank-wide guidelines or directives for engaging with the Global Fund. The fact that Fund Portfolio Managers generally have a different professional background from the Bank’s health sector task team leaders. The fact that Global Fund uses a disease-specific monitoring system to support its performance-based funding approach to development assistance. The different project cycle of the Global Fund compared to the World Bank. The lack of financial compensation for providing technical support. The absence of a Memorandum of Understanding between the Global Fund and the World Bank for collaborating at the country level. The limited country presence of the Global Fund. (Their Fund Portfolio Managers are based in Geneva.) 0% 20% 40% 60% 80% 100% Much easier Somewhat easier Neither easier nor more difficult  Somewhat more difficult Much more difficult Appendix Q 144 Question 10 (to Global Fund Staff): In your opinion, do the following factors make it easier or more difficult for Global Fund managers, staff or agents to engage with the World Bank at the country level? Answer all questions on a five-point scale from “much easier� to “much more difficult�. (Sorted in descending order. See Figure 8.) Neither Some- Some- Much Much easier what Response by Sub-question what more Total easier nor more more easier difficult difficult difficult Q14e: The relatively strong country presence of the World Bank. (Their Task Team Leaders are often based in the country, depending on the 10 25 13 2 0 50 size of the Bank’s country program.) Q14i: The fact that the World Bank provides technical and/or financial support to strengthen country-level health sector monitoring and 6 29 15 0 0 50 evaluation systems. Q14l: The fact that a Task Team Leader is responsible for overseeing the implementation of World Bank-supported projects and technical 4 17 28 1 0 50 assistance activities. Q14b: The success of the Global Fund in mobilizing substantial donor 4 13 30 3 0 50 resources to combat the three diseases. Q14o: The presence of other mechanisms through which the World Bank and the Global Fund may interact, such as the AIDS Strategy and Action Plans (ASAPs), the Joint Assessment of National Strategies 5 20 14 8 3 50 (JANS), and the Joint Funding Platform for Health Systems Strengthening. Q14d: The focus of the Global Fund on low-income countries. 1 8 41 0 0 50 Q14m: The fact that Bank health sector Task Team Leaders have a 0 3 41 5 1 50 different professional background from Fund Portfolio Managers. Q14f: The World Bank requirement of Bank budgetary or trust fund resources for everything done by staff, including provision of technical 0 6 29 14 1 50 support. Q14k: The fact that World Bank-supported projects are implemented by government agencies (although governments may enlist NGOs and civil 1 6 28 9 6 50 society organizations for implementation). Q14c: The fact that the World Bank provides financial assistance 0 4 30 12 4 50 primarily in the form of loans as opposed to grants. Q14a: The absence of written Global Fund guidelines or directives for 0 3 26 19 2 50 engaging with the World Bank at the country level. Q14h: The fact that World Bank investment projects and technical assistance activities are based on a Country Assistance Strategy (CAS) negotiated between the World Bank and the Government. (The health 0 8 18 19 5 50 sector, including World Bank funding for it and associated budget support for project supervision, has to compete with other sectors for its place in the CAS.) Q14g: The different project cycle of the World Bank compared to the Global Fund. (Bank-financed projects are generally prepared 0 2 20 24 4 50 collaboratively by Government staff and consultants, with World Bank staff support, and negotiated between the Government and the Bank.) Q14j: The fact that the World Bank is less engaged with civil society 0 1 21 17 11 50 organizations compared to the Global Fund. Q14n: The absence of a Memorandum of Understanding between the 0 1 18 23 8 50 Global Fund and the World Bank for collaborating at the country level. 145 Appendix Q Figure 8. Global Fund: In your opinion, do the following factors make it easier or more difficult for Global Fund managers, staff or agents to engage with the World Bank at the country level? The relatively strong country presence of the World Bank. (Their Task Team Leaders are often based in the country.) The fact that the World Bank provides technical and/or financial support to strengthen country-level health sector monitoring and evaluation systems. The fact that a Task Team Leader is responsible for overseeing the implementation of World Bank- supported projects and technical assistance activities. The success of the Global Fund in mobilizing sub- stantial donor resources to combat the three diseases. The presence of other mechanisms through which the World Bank and the Global Fund may interact, such as ASAPs, JANS, and the Joint Funding Platform. The focus of the Global Fund on low-income countries. The fact that Bank health sector Task Team Leaders have a different professional background from Fund Portfolio Managers. The World Bank requirement of Bank budgetary or trust fund resources for everything done by staff, including provision of technical support. The fact that World Bank-supported projects are implemented by government agencies. The fact that the World Bank provides financial assistance primarily in the form of loans. The absence of written Global Fund guidelines for engaging with the World Bank at the country level. The fact that World Bank investment projects and technical assistance activities are based on a Country Assistance Strategy (CAS). The different project cycle of the World Bank compared to the Global Fund. The fact that the World Bank is less engaged with civil society organization compared to the Global Fund. The absence of a Memorandum of Understanding between the Global Fund and the World Bank for collaborating at the country level. 0% 20% 40% 60% 80% 100% Much easier Somewhat easier Neither easier nor more difficult Somewhat more difficult Much more difficult Appendix Q 146 Question 11 (to World Bank TTLs). The Global Fund and PEPFAR (the U.S. President’s Emergency Fund for AIDS Relief) are now the two largest providers of financial resources for combating communicable diseases in developing countries. In your opinion, to what extent has their presence had the following impacts on the World Bank since the two programs were established in 2002 and 2003, respectively? Much No Much Don't Response by Sub-question Higher Lower Total higher Change lower Know World Bank lending for combating communicable diseases is LOWER OR HIGHER 0 2 4 20 11 2 39 than it otherwise would have been. World Bank lending to the overall health sector is LOWER OR HIGHER than it otherwise would 0 2 11 16 8 2 39 have been? World Bank lending for strengthening health systems is LOWER OR HIGHER than it 0 5 16 11 4 3 39 otherwise would have been. High Substantial Modest Negligible Don't Response by Sub-question Total impact impact impact impact know The way in which the World Bank operates at the country level has become MORE INCLUSIVE than it otherwise would have been, 2 4 13 15 5 39 involving more engagement with civil society organizations. World Bank lending to the health sector has become MORE RESULTS-FOCUSED than it 2 7 8 16 6 39 otherwise would have been. World Bank-supported activities reflect a greater degree of COUNTRY OWNERSHIP 2 8 7 16 6 39 than would otherwise have been the case. 147 Appendix Q Figure 9. World Bank Task Team Leaders: In your opinion, to what extent has the presence of the Global Fund and PEPFAR had the following impacts on the World Bank since the two programs were established in 2002 and 2003, respectively? World Bank lending for combating communicable diseases is lower or higher than it otherwise would have been. World Bank lending to the overall health sector is lower or higher than it otherwise would have been? World Bank lending for strengthening health systems is lower or higher than it otherwise would have been. 0% 20% 40% 60% 80% 100% Much lower Lower No Change Higher Much higher The way in which the World Bank operates at the country level has become more inclusive than it otherwise would have been, involving more engagement with civil society organizations. World Bank lending to the health sector has become more results-focused than it otherwise would have been. World Bank-supported activities reflect a greater degree of country ownership than would otherwise have been the case. 0% 20% 40% 60% 80% 100% Negligible Modest Substantial High Source: IEG Survey of World Bank HNP Task Team Leaders and Global Fund Secretariat staff, administered in March 2011. Appendix Q 148 Question 11 (to Global Fund Staff). The Five-Year Evaluation of the Global Fund was completed in May 2009. In your opinion, to what extent have the findings and recommendations of the Five-Year Evaluation had the following impact on the Global Fund? (Sorted in descending order. See Figure 10.) Response by Sub-question High Substantial Modest Negligible Total The Global Fund has sharpened its practices in the areas of PROCUREMENT, AUDIT, AND ANTI-CORRUPTION. 7 29 13 1 50 The Global Fund has become MORE PROGRAM-BASED, as opposed to individual grant based, in its funding decisions. 7 26 15 2 50 The Global Fund is improving the ALIGNMENT of its grants with each country’s planning and budgeting cycles. 9 23 16 2 50 Global Fund grants are providing more support to STRENGTHENING NATIONAL HEALTH MANAGEMENT 3 21 23 3 50 INFORMATION SYSTEMS. The Global Fund is devoting more resources to ENHANCING THE CAPACITY AND EFFECTIVENESS OF CCMS in their 0 22 25 3 50 full range of functions. Global Fund grants are putting more focus on DISEASE- PREVENTION ACTIVITIES, as opposed to treatment, care 2 13 29 6 50 and support activities, taking into account the local context of each epidemic. The Global Fund has improved its ability TO ADEQUATELY REWARD AND RETAIN ITS STAFF. 1 4 24 21 50 149 Appendix Q Figure 10. To what extent have the findings and recommendations of the Five-Year Evaluation had the following impacts on the Global Fund? The Global Fund has sharpened its practices in the areas of procurement, audit, and anti- corruption. The Global Fund is improving the alignment of its grants with each country’s planning and budgeting cycles. The Global Fund has become more program- based, as opposed to individual grant based, in its funding decisions. Global Fund grants are providing more support to strengthening national health management information systems. The Global Fund is devoting more resources to enhancing the capacity and effectiveness of CCMs in their full range of functions. Global Fund grants are putting more focus on disease-prevention activities, as opposed to treatment, care and support activities, taking into account the local context of each epidemic. The Global Fund has improved its ability to adequately reward and retain its staff. 0% 20% 40% 60% 80% 100% High Substantial Modest Negligible Appendix Q 150 Question 12 (to World Bank TTLs). Which of the following do you consider the most important COMPARATIVE ADVANTAGES OF THE GLOBAL FUND among international development agencies in terms of achieving positive results for the three diseases at the country level? Please rank the top five in order of importance (1 = most important, 2 = second most important, etc.) Mobilizing donor resources to combat the three diseases in the short term Promoting country-owned strategies and other responses to combat the three diseases Sustaining financial resources to combat the three diseases over the long term Facilitating an effective rapid response to the three diseases in the short term Developing specialized expertise in the prevention, treatment, and care and support in dealing with the three diseases Lowering the transactions costs of development assistance from the point of view of donors Promoting a results focus to development assistance Average Lowering the transactions costs of development assistance from the point of view of beneficiaries Building institutional and human resource capacity to combat the three diseases over the long term Ensuring that aid resources are used efficiently and effectively 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 151 Appendix Q Question 12 (To Global Fund Staff). Which of the following do you consider to be the most important COMPARATIVE ADVANTAGES OF THE WORLD BANK among international development agencies in terms of achieving positive results at the country level? Facilitating dialogue with Ministries of Finance, Planning and other Central Ministries. Helping to improve financial management and procurement. Providing finance for long-term investments in health infrastructure. Helping to design and prepare investment projects in the health sector. Helping to formulate appropriate strategies and policies in the health sector. Helping to reform health care finance systems over the long term. Helping to strengthen health delivery systems over the long term. Average Organizing and facilitating policy dialogue at the national, sectoral and project levels. Managing country-specific donor trust funds. Supervising investment projects and field operations. 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Appendix Q 152 Question 13. What changes would you like to see in the Global Fund and the World Bank to facilitate greater engagement between the two organizations to achieve positive results at the country level, while also respecting each organization’s fundamental purposes and principles? Responses by Organization Yes No Don’t Know Total The Global Fund's participating in multi-donor Sector-Wide Approaches (SWAps) in support of nationally-defined programs to combat the three diseases. World Bank Task Team Leaders 36 0 3 39 Global Fund – All Clusters 22 20 7 49 The Global Fund’s donors establishing a trust fund at the World Bank for financing Bank-supervised technical assistance in support of Global Fund-supported activities. World Bank Task Team Leaders 35 1 3 39 Global Fund – All Clusters 16 18 15 49 The Global Fund’s co-financing World Bank projects in the health sector, like bilateral donors currently co-finance Bank projects. World Bank Task Team Leaders 32 3 4 39 Global Fund – All Clusters 17 26 6 49 The World Bank’s being an ex officio member of the Country Coordinating Mechanism wherever the Bank is an active player in the health sector in the country. World Bank Task Team Leaders 26 7 6 39 Global Fund – All Clusters 40 4 5 49 The Global Fund’s providing direct financing for World Bank-supervised technical assistance activities in support of Global Fund-supported activities. World Bank Task Team Leaders 25 5 9 39 Global Fund – All Clusters 19 19 11 49 The two organizations' establishing an active staff exchange program. World Bank Task Team Leaders 23 8 8 39 Global Fund – All Clusters 42 3 4 49 The World Bank’s playing the role (for a fee) of the Local Fund Agent overseeing selected Global Fund grants, like Bank staff currently oversee projects financed by the Global Environment Facility. World Bank Task Team Leaders 21 12 6 39 Global Fund – All Clusters 16 27 6 49 The Global Fund’s using the World Bank’s Project Implementation Unit as the Principal Recipient for selected Global Fund grants, and World Bank staff overseeing these grants like for Bank projects. World Bank Task Team Leaders 20 12 7 39 Global Fund – All Clusters 14 30 5 49 153 Appendix Q Figure 11. What changes would you like to see in the Global Fund and the World Bank to facilitate greater engagement between the two organizations to achieve positive results at the country level, while also respecting each organization’s fundamental purposes and principles? (Percent “Yes�) The Global Fund's participating in multi-donor Sector-Wide Approaches in support of nationally- defined programs to combat the three diseases. The Global Fund’s donors establishing a trust fund at the World Bank for financing Bank-supervised TA in support of Global Fund-supported activities. The Global Fund’s co-financing World Bank projects n the health sector, like bilateral donors currently co- finance Bank projects. The World Bank’s being an ex officio member of the CCM wherever the Bank is an active player in the health sector in the country. The Global Fund’s providing direct financing for World Bank-supervised TA in support of Global Fund-supported activities. The two organizations' establishing an active staff exchange program. The Global Fund’s using the World Bank’s Project Implementation Unit as the Principal Recipient for selected Global Fund grants, and World Bank staff overseeing these grants like for Bank projects. 0% 20% 40% 60% 80% 100% GF � All Clusters WB �Task  Team Leaders 154 Appendix R. Persons Consulted Name Position Organization Michel Kazatchkine Executive Director Global Fund Debrework Zewdie Deputy Executive Director Global Fund Enrico Mollica Chief of Staff, Office of the Executive director Global Fund George Shakarishvili Senior Advisor, Health Systems Strengthening Global Fund Paula Hacopian Manager, Board Relations Global Fund John Parsons Inspector General Global Fund Lola Dare Chair, Technical Evaluation Reference Group Global Fund Technical Evaluation Group interview and discussion Global Fund Reference Group Heather Allan Director, Corporate Services Cluster Global Fund Josephine M. Mutuku Director, Human Resources, Administration Global Fund and Internal Communications Unit William Patton Director, Country Programs Cluster Global Fund Oren Ginzburg Unit Director, Quality Assurance and Support Global Fund Services Unit David Winters Manager, Country Coordinating Mechanisms Global Fund Cecile Collas Program Officer, Country Coordinating Global Fund Mechanisms Krishna Vadrevu Program Officer, Country Coordinating Global Fund Mechanisms Swarup Sarwar Unit Director, Asia Global Fund Elmar Vinh-Thomas Regional Team Leader, East Asia & the Pacific Global Fund Lelio Marmora Regional Team Leader, Latin America & the Global Fund Caribbean Olivier Cavey Fund Portfolio Manager, East Asia & the Global Fund Pacific Berdnikov Maxim Fund Portfolio Manager, East Asia & the Global Fund Pacific Matias Gomez Fund Portfolio Manager, Latin America & the Global Fund Caribbean Annelise Hirschmann Fund Portfolio Manager, Latin America & the Global Fund Caribbean Luca Ochini Fund Portfolio Manager, Latin America & the Global Fund Caribbean Artashes Mirzoyan Fund Portfolio Manager, South & West Asia Global Fund Daniela Mohaupt Fund Portfolio Manager, South & West Asia Global Fund S. Scott Morey Fund Portfolio Manager, South & West Asia Global Fund Sylwia Murray Fund Portfolio Manager, South & West Asia Global Fund Patience Musanhu Fund Portfolio Manager, Southern Africa Global Fund 155 Name Position Organization Alberto Passini Fund Portfolio Manager, Southern Africa Global Fund Tatanya Peterson Fund Portfolio Manager, Southern Africa Global Fund Christoph Benn Director, External Relations and Partnerships Global Fund Cluster Jon Liden Unit Director, Communications Unit Global Fund Sandii Lwin Manager, Bilateral and Multilateral Partnerships Global Fund Team, Partnerships Unit Rifat Atun Director, Strategy, Performance and Evaluation Global Fund Cluster Olusoji Adeyi Unit Director, Affordable Medicines Facility Global Fund for Malaria (AMFm) Unit Edward Addai Unit Director, Monitoring and Evaluation Unit Global Fund Sai Kumar Pothapregada Sr. Technical Officer, Monitoring and Global Fund Evaluation Unit Mary Bendig Sr. Evaluation Officer, Monitoring and Global Fund Evaluation Unit (?) Daniel Low-Beer Director, Performance, Impact and Global Fund Effectiveness Unit Kirsi Viisainen Manager, Program Effectiveness Team Global Fund Ruwan De Mel Unit Director, Strategy and Policy Development Global Fund Unit Sarah L. Churchill Manager, Country Proposals Team Global Fund Geoffrey Lamb Gates Foundation Todd Summers Gates Foundation Helen Evans Deputy Chief Executive Officer GAVI Alliance Peter Hansen Head, Monitoring & Evaluation, Policy and GAVI Alliance Performance Abdallah Bchir Senior Program Officer, Evaluation GAVI Alliance Joseph Fortunak Assoc Prof Chemistry & Pharmaceutical Howard University Sciences Martin Vaessen Sr. Vice President MACRO International Leo Ryan Vice President MACRO International Sangheeta Mukherji Lead Evaluator for Study Area 2 MACRO International James Sherry Lead Evaluator for Synthesis Report MACRO International 156 Name Position Organization Sebastian Mollo di Intelligence Director Pharmaceutical Massa Security Institute (PSI) Susan Griffey Vice President & Director, Evaluation Center Social and Scientific Systems Rosemary Barber- Team Lead, Professor Emerita, Columbia Social and Scientific Madden University, School of Public Health Systems William Brieger Professor, Health Systems Program, Social and Scientific Department of International Health, Johns Systems Hopkins Alden Zecha CFO and Strategist Sproxil Ltd Paul De Lay Deputy Executive Director, Program UNAIDS Tim Martineau Director, Technical and Operational Support UNAIDS Department Deborah Rugg Chief, Monitoring and Evaluation, UNAIDS Evidence, Monitoring and Policy Department Nils Daulaire Director of Global Health Affairs U.S. Department of Health and Human Services Ties Boerma Director, Health Statistics and Informatics World Health Organization Timothy Evans Assistant Director- General, Information, World Health Evidence, and Research Organization Hiroki Nakatani Assistant Director-General, HIV/AIDS, World Health Tuberculosis, Malaria and Neglected Tropical Organization Diseases. Ran Wei Medical Officer, HIV/AIDS, Tuberculosis, World Health Malaria and Neglected Tropical Diseases Organization Cristian Baeza Sector Director, HDNHE, June 2010 – present World Bank Julian Schweitzer Sector Director, HDNHE, 2007–2010 World Bank Mukesh Chawla Sector Manager, HDNHE, 2008–2011 World Bank Nicole Klingen Sector Manager, HDNHE, July 2011 – present World Bank Ok Pannenborg Senior Health Advisor, HDNHE World Bank Armin Fidler Adviser, Policy and Strategy, HDNHE World Bank Peter Berman World Bank Finn Schleimann Sr. Health Specialist, HDNHE World Bank 157 Name Position Organization David Wilson Program Director, Global HIV/AIDS Program World Bank Janet Leno ASAP Coordinator, Caribbean, East/Southern World Bank Africa, Asia Rosalia Rodriguez- Senior Monitoring and Evaluation Specialist, World Bank Garcia HDNGA Susan McAdams Director, CFPMI World Bank Alexandru Cebotari Financial Officer, CFPMI World Bank Veronique Bishop Sr. Financial Officer, CFPMI World Bank Siv Tokle Sr. Operations Officer, ENVGC World Bank Andrea Stumpf Lead Counsel, LEGCP World Bank Yvonne Tsikata Country Director, Caribbean Countries World Bank Eva Jarawan HNP Sector Manager, Africa Region World Bank Juan Peblo Uribe HNP Sector Manager, East Asia & the Pacific Keith Hansen HDN Sector Director, Latin America & the World Bank Caribbean Region Joana M. Godinho HNP Sector Manager, Latin American and World Bank Caribbean Region Akiko Maeda HNP Sector Manager, Middle East & North World Bank Africa Region Julie McLaughlin HNP Sector Manager, South Asia Region World Bank John May Lead Population Specialist, Africa Region World Bank Patrick Osewe Lead Specialist, AFTHE World Bank Noel Chisaka Sr. Public Health Specialist, AFTHE World Bank Vincent Turbat Consultant, EASHD World Bank Hope Phillips Sr. Operations Officer, EASHH World Bank Patricio Marquez Lead Health Specialist, ECSH1 World Bank Nedim Jaganjac Sr. Health Specialist, ECSH1 World Bank Marcelo Bortman Sr. Public Health Specialist, Latin America and World Bank Caribbean Region Rafael Cortez Sr. Health Economist, LCSHH World Bank Fernando Lavadenz Sr. Health Specialist, LCSHH World Bank Shyan Chau HNP task team leader for Caribbean Region World Bank Fernando Montenegro Sr. Economist, LCSHH World Bank Torres 158 Persons Consulted during the Country Visit to Brazil, April 2010 Person Position Organization Government of Brazil Dr. Draurio Barreira Head National Tuberculosis Program, Secretary for Health Surveillance, Epidemiological Surveillance Department, Ministry of Health Eduardo Luiz Barbosa Deputy Director STS and AIDS Department, Secretariat for Health Surveillance, Ministry of Health Jose Lazaro de Brito Coordinator National Malaria Program, Ministry of Ladislau Health, Brasilia Global Fund Implementers and Agents Nadja Faraone General Coordinator Movimento Social de Tuberculose, São Paulo, and Vice Chair of Country Coordinating Mechanism Dr. Germano Gerhardt Filho President Fundação Ataulpho de Paiva (FAP) and Principal Recipient for the Global Fund Project on TB Dr.Cristina Boaretto Tuberculosis Project Fundação para o Desenvolvimento Coordinator, the Global Cientifico e Tecnologico em Saude Fund (FIOTEC) Alexandre Milagres Fundação Ataulpho de Paiva (FAP) and Principal Recipient for the Global Fund Project on TB Patricia Muricy, and Enterprise Risk Services, Deloitte Touche Mariangela Louvain Pinudo Tohmatsu, Local Fund Agent Dr. Carlos Eduardo P. Global Fund Malaria Fundação Faculdade de Medicina (FFM), Corbett Project Coordinator Universidade de São Paulo Neusa T. C. Burbarelli Manager Health and Work Safety of editora abril and Chairpeson of the Conselho Empresarial de AIDS, CENAIDS Dr. Alexandre de Marca Gerente de Saude e Bem Estar, Confederação Nacional de Comercio de Bens, Serviços e Turismo Dr. Elza Berquió Demography and Centro Brasileiro de Analise e Planejamento, Family Health CEBRAP Researcher Cristiane Jose Manager Saude e Qualidade de Vida, Walter Duran, Manager of Social Responsibility of Phillips to Brasil World Bank Michele Gragnolati  Sector Leader, HD World Bank Brasilia Office  Romero Rocha  Health Economist, HD World Bank Brasilia Office  159 Person Position Organization Alexandre Abrantes   Brazil Portfolio  Manager, former HNP  Sector Manager  Makhtar Diop   Country Director for  Brazil  Development Partners   Patricia Paine  Senior Technical  Health Program, USAID, Brazil, U.S. Advisor  Embassy  Dr. Pedro Chequer  Country Coordinator UNAIDS, Brazil Naiara G. da Costa Chaves  Program Officer UNAIDS, Brazil Alfonso Tenorio Gnecco  Profissional  Pan American Health Organization�WHO,  Internacional,  Brazil  Tuberculose  Persons Consulted during the Country Visit to Burkina Faso, April 2010 Person Position Organization Government of Burkina Faso Zacharie Balima Coordinator Program d’Appui au Développement Sanitaire (PADS) Sary Mathurin Dembele Manager National Tuberculosis Program Seydou K. Kabre Management CNLS Coordinator Estelle Kabore Liaison Direction Générale de la Coopération, Ministère de l’Economie et des Finances. Lene Sebgo Director General Direction Générale de la Coopération, Ministère de l’Economie et des Finances. Joseph Tiendrebeogo Director CNLS Wamarou Traore Team Leader CNLS Global Fund Implementers and Agents Victor Bonkoungou Tuberculosis Program PAMAC Officer Cheik Coulibaly Consultant Swiss TPH Flore-M.Gisele Coulibaly Tuberculosis Project PAMAC Officer Mamadou Dao HIV/AIDS Prevention PAMAC Program Officer Demba Diack Institutional Support PAMAC Program Officer Odette Ky-Zerbo Evaluation Program PAMAC Officer 160 Person Position Organization Christine Kafando Vice-Chair of CCM Boureime Kologo Director of Operations PAMAC Amadou Ouedraogo Malaria Program Officer PAMAC Jean Pare Pharmacist Pharmacie de la Concorde Sedogo Director Comite National Catholique de lutte contre le SIDA Eric Somda Secretary CCM Agathe Sy Program Director for PLAN International Strategy Mahamadou Tounkara Resident Representative PLAN International Kaspar Weiss (Consulted Senior Public Health Swiss TPH By Telephone) Specialist World Bank H Ousemane Diadie Task Team Leader Burkina Faso Country Office Galina Sotirova Country Manager Burkina Faso Country Office Jean-Jacques St Antoine Health Cluster Leader AFTHE Development Partners Francoise Bigirimania HIV/AIDS Program WHO Officer Djamila Khady Cabral Representative WHO Awa Faye Country Coordinator UNAIDS Paulina Julia Nurse United States Embassy Souhaib Khayati Program Officer Cooperation Italienne Haritiana Rakotomamonjy HIV/AIDS Program UNICEF Director Herve Peries Resident Representative UNICEF Jan Van Der Horst Health Advisor Embassy of the Netherlands 161 Persons Consulted during the Country Visit to Cambodia, May 2010 Person Position Organization Government of Cambodia Secretary of State for Professor Eng Huot Health and Deputy Ministry of Health Minister of Health Vice Chair national Dr. Tia Phalla National AIDS Authority AIDS Authority Director Global Fund Implementers and Agents Dr. Mao Tan Eang Director National Center for TB and Leprosy Control National Center for Parasitology, Dr. Dong Socheat Director Entomology and Malaria Control National Center for HIV/AIDS, Dr. Mean Chhivun Director Dermatology and STD National Center for HIV/AIDS, Dr. Ly Penh Sun Deputy Director Dermatology and STD Manager, Principal Dr. Or Vandine Recipient of Global MOH FundATM Dr. Kiv Sokha Chief, M&E Team PR MOH Dr. Chiv Bunthy Secretariat Manager CCC, Global FundATM Kith Vanthy Administrative Officer CCC, Global FundATM Dr. Sim Somuny Executive Director MEDICAM CCC Chair, and Phon Yun Sakara Director HIV/AIDS CCC Vice Chair and PACT Cambodia Program, Dr. Kim Souvaun Local Fund Agent Swiss Tropical Institute World Bank Annette Dixon Country Director Cambodia, Lao PDR, Malaysia, Thailand and Representative for Myanmar Qimiao Fan Country Manager, Cambodia World Bank Jeeva Perumalpillai-Essex Sustainable South East Asia Development Leader Senior Country Stephane Guimbert Cambodia Economist, Timothy Johnston Senior Health Specialist Cambodia Cam Cambodia, Lao PDR, Malaysia, Luc Lecuit Sr. Operations Officer Thailand and Representative for Myanmar 162 Person Position Organization Development Partners WHO Representative WHO Cambodia Dr. Pieter van Maaren and CCC Vice Chair Scientist, Malaria and Dr. Steven Bjorge WHO Cambodia Vector Borne Diseases Dr. Rajendra Yadav WHO Cambodia Savina Ammassari M&E Advisor UNAIDS Cambodia Misa Tamura Senior Advisor Embassy of Japan Project Formulation Sasaki Yumiko JICA Cambodia Advisor (Health) Conseiller de Dominique Freslon Cooperation et d’Action Embassy of France Culturelle Charge de Mission de Gilles Angles Cooperation Embassy of France Multilaterale Others Kheng Sophal Executive Director Positive Women of Hope Organization Cambodian People Living with HIV/AIDS Keo Chen National Coordinator Network Cambodia Business Coalition on AIDS Ly Tek Heng Chair Garment Manufacturers Assoc Cambodia Business Coalition on AIDS Vara Kong Chairman CBCA Vuthuy Huy Executive Manager CBCA NGO members of HIV AIDS Coordinating Committee Persons Consulted during the Country Visit to Nepal, May 2010 Person Position Organization Dr. Krishna Kumar Rai Director National Center for AIDS and STD Control Dr. Ramesh Kumar Kharel Deputy Director National Center for AIDS and STD Control Dr. Shyam S. Mishra Vice Chairperson HIV/AIDS and STI Control Board Mr. Damar Prasad Ghimire Director/Member HIV/AIDS and STI Control Board Mr. Rajiv Kafle Vice Chair Country Coordinating Mechanism (also) Director National Association of People Living with HIV/AIDS Mr. Shailesh Dhimal Administration and National Association of People Living with Finance Officer HIV/AIDS Mr. Sunil Pant Member Nepal Constituent Assembly (also) Director Blue Diamond Society and Federation of Sexual and Gender Minorities 163 Person Position Organization Mr. Krishna Prasad Bista Director General Family Planning Association of Nepal Dr. Giridhari Sharma Deputy Director General Family Planning Association of Nepal Paudel and Chief of the Program Dr. Pulki Chaudhary Director, Global Fund Family Planning Association of Nepal Project Dr. Navin Thapa Director Resource Family Planning Association of Nepal Mobilisation and External Affairs| Dr. Maria Elena G. Filio- Country Coordinator, UNAIDS Borromeo Nepal and Bhutan Dr. Lin Aung Representative, Nepal WHO Dr. George Ionita Project Manager UNDP HIV/AIDS Programme Management Unit Ms. Savita Acharya Senior Programme UNDP Officer HIV/AIDS Programme Management Unit Ms. Anne M. Peniston Director, Office of USAID Health and Family Planning Mr. Clifford Lubitz Deputy Director, Office USAID of Health and Family Planning Ms. Susan Clapham Country Director (?) DFID Ms. Susan Goldmark Country Director World Bank Albertus Voetberg Lead Health Specialist World Bank Dr. Nastu Pd. Sharma Health Sector Specialist World Bank Mr. Madan K. Sharma Local Funding Agent PricewaterhouseCoopers Persons Consulted during the Country Visit to the Russian Federation, June 2010 Person Position Organization Government of the Russian Federation Anna V. Korotkova Deputy Director, Central Research Institute for Health International Affairs Organization and Information, Ministry of Health and Social Development Global Fund Implementers and Agents Urban Weber Unit Director Global Fund, Geneva Dmitriy A. Goliaev Global Fund Project Russian Health Care Foundation Director 164 Person Position Organization Tatiana Ye. Fomicheva Acting Director, Russian Health Care Foundation Tuberculosis Component Dimitry Sukhov Manager, Advisory KPMG, Moscow, Local Fund Agent Performance Boris Lvov Partner, Performance KPMG, Moscow, Local Fund Agent and Technology, Russia and CIS Valentin I. Pokrovsky Director Central Research Institute for Epidemiology Country Coordinating Mechanism Chair Ludmila V. Korshunova CCM Secretary Country Coordinating Mechanism World Bank Patricio Marquez Lead Health Specialist World Bank, Washington Vladimir A. Grechuka Acting Director ZAO Prospect Former Director World Bank TB/AIDS Project, Moscow Development Partners Dmitry Pashkevitch Medical World Health Organization Officer/Coordinator, TB Control Programme Elena Vovc Medical Officer Health Organization HIV/AIDS Programme Coordinator Denis Broun Regional Director UNAIDS, Moscow Lisa Carty Global Health Program Center for Strategic and International Former Regional Studies Director UNAIDS, Moscow Cheryl Kamin Health Specialist USAID, Moscow Nina B. Khurieva Tuberculosis Program USAID, Moscow Specialist Alexander Golubkov Tuberculosis Specialist Partners in Health, Boston Former member of Tomsk CCM Evgeniy Petunin Programme Director Russian Harm Reduction Network Alexei V. Bobrik Executive Director Open Health Institute, Moscow Grigory V. Volchenkov Oblast Chief Doctor Vladimir Oblast, Tuberculosis Dispensary Andrei G. Zirin Director Department of Health, Vladimir Oblast Judyth Twigg Professor of Virginia Commonwealth University Government and Public Affairs 165 Persons Consulted during the Country Visit to Tanzania, June 2010 Person Position Organization Government of Tanzania National Malaria Control Program, Ministry Dr. Alex M. Mwita Program Manager of Health and Social Welfare Chairperson and Dr. Fatma Mirisho TACAIDS EM Executive Director Mrs. Blandina Nyoni Permanent Secretary Ministry of Health National Malaria Control Program, Ministry Nick Brown Team Leader of Health and Social Welfare Preventive Services, Ministry of Health and Dr. Donan W. Mmbando Director Social Welfare Global Fund Dr. Bwijo A. Bwijo TACAIDS, Prime Minister’s Office Coordinator National Tuberculosis and Leprosy Program, Dr. S.M. Egwaga Program Manager Ministry of Health and Social Welfare Global Fund Implementers and Agents Mr. Nada A. Margwe Director PriceWaterhouseCoopers, Local Fund Agent Price Waterhouse Coopers, Local Fund Focus Lutinwa Director Agent Dr. Amos Nyirenda Program manager Global Fund to Fight AIDS, TB, Malaria World Bank Senior Operations Chyo Kanda World Bank Country Office Officer Denis Biseko Senior PSM Specialist World Bank Country Office Emmanual Malangalila Consultant on Health World Bank Country Office John McIntire Country Director World Bank Country Office Development Partners Luc Barriere-Constantin Country Coordinator UNAIDS Elise Jensen HIV/AIDS Team Leader USAID/Tanzania Robert F. Cunnane Mission Director USAID/Tanzania Richard Kasasela Executive Director AIDS Business Coalition Dan Craun-Selka Country Director PACT Tanzania Daniel Crapper Executive Director Population Services International (PSI) Development-Health & HIV/AIDS, High Christopher Armstrong Counsellor Commission of Canada Health & HIV/AIDS, Embassy of the Dr. Rik Peeperkorn First Secretary Kingdom of the Netherlands Tanzania Network of Women Living with Joan Chamungu National Coordinator HIV/AIDS The Global Program Review Series The following reviews are available from IEG. Volume #1, Issue #1: ProVention Consortium Issue #2: Medicines for Malaria Venture Issue #3: Development Gateway Foundation Issue #4: Cities Alliance Volume #2, Issue #1: Critical Ecosystem Partnership Fund Issue #2: Association for the Development of Education in Africa Issue #3: Population and Reproductive Health Capacity Building Program Issue #4: International Land Coalition Volume #3, Issue #1: Consultative Group to Assist the Poor Issue #2: Global Development Network Issue #3: Global Forum for Health Research Issue #4: Global Invasive Species Program Volume #4, Issue #1: Stop Tuberculosis Partnership Issue #2: International Assessment of Agricultural Knowledge, Science, and Technology for Development Issue #3: The Global Water Partnership Volume #5, Issue #1: Multi-Donor Trust Fund for the Extractive Industries Transparency Initiative Issue #2: The Mesoamerican Biological Corridor Issue #3: Marrakech Action Plan for Statistics, Partnership in Statistics for Development in the 21st Century, and Trust Fund for Statistical Capacity Building Volume #6, Issue #1: The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the World Bank’s Engagement with the Global Fund GPR The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 to mobi- lize large-scale donor resources for the specific purpose of reducing infections, illness, and death caused by the three diseases. The Global Fund has since become the largest of the 120 global and regional partnership programs in which the World Bank is currently involved, disbursing more than $3 billion in grants to developing and transition countries in 2010. The World Bank plays three major roles in the Global Fund: (a) as the trustee of donor contributions to the Global Fund, (b) in the corporate governance of the program, and (c) as a development partner at the global and country levels. This Review found that the Bank has had extensive engagement with the Global Fund at the global level through the Global HIV/AIDS Program, the International Health Partnership, and related initiatives, but has been less engaged at the country level. The Global Fund has fostered new approaches to development assistance. This Review found that its Country Coordinating Mechanisms have successfully brought country-level stakeholders together to submit grant proposals to the Global Fund, but have lacked the authority and the resources to exercise effective oversight of grant implementation. The situ- ation has improved in recent years in terms of the World Bank and other partnersʼ providing technical assistance in support of Global Fund activities, but these technical support func- tions need to be defined with greater clarity and formality within the context of improved donor harmonization. Collective donor efforts have contributed to increased availability and use of disease-con- trol services, particularly for HIV/AIDS, and increased coverage of affected communities. However, sustaining client countriesʼ disease-control programs in the face of decelerating external support will require a substantially more coordinated approach than has occurred to date. The scarce resources available to fight the three diseases — including those raised by each country and those provided by external partners — need to be allocated collectively and proactively in each country in accordance with a long-term strategy for fighting each dis- ease that is agreed among all the principal stakeholders.