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2011 Global Fund Partnership Forum e-Consultations

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Adding Your Voice to the Global Fund’s 2012 — 2016 Strategy

WORKING TOGETHER, SHAPING OUR FUTURE
ACCESS ACCOUNTABILITY RIGHTS
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CONTENTS
THE PARTNERSHIP FORUM E-CONSULTATIONS: YOUR VOICE AND THE GLOBAL FUND STRATEGY Background and methodology PART I: MULTI-LANGUAGE E-FORUM DISCUSSIONS Lives Saved And Value For Money Addressing Human Rights In Country Settings Improving Country-Level Partnerships And Alignment PART II: ONLINE SURVEY Highlights of e-survey responses Results Maximizing Impact: Using Investments In The Three Diseases To Deliver Broader Health Outcomes Within Community And National Health Systems Delivering on a human rights approach for the three diseases: where should this take us? Using the money wisely: Funding the right things Using the money wisely: Strengthening governance and oversight to get it right Implementing with increased impact Ideas for Innovation and improvement ANNEX 1: SURVEY QUESTIONNAIRE 2 3 4 5 9 13 16 17 18

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THE PARTNERSHIP FORUM E-CONSULTATIONS: YOUR VOICE AND THE GLOBAL FUND STRATEGY
In 2002, the Global Fund was created to save lives and restore hope to millions of people. Eight years on, Global Fund nancing has contributed to saving more than 6.5 million lives and it has achieved this through the collective action and commitment of all sectors of society. The Global Fund’s overall governance framework fully embodies this shared action and commitment. Every 2 to 2.5 years – the Global Fund Board convenes a ‘Partnership Forum’ to consult with all stakeholders on its policies and strategies. The uniqueness of each Partnership Forum is the open and participatory way that all sectors of society can be engaged in collectively shaping the work of the Global Fund. Working within the scope of the overall theme “Working Together, Shaping the Future (Access, Accountability, Rights)”, the 2011 Partnership Forum consultations comprise: A multi-language e-Survey, produced in English, Spanish, French and Russian online for six weeks, promoted across the globe A moderated e-Forum discussion in four languages – English, Spanish, Russian and French over a six week period. A Chinese language e-Forum discussion was also hosted. Country-level interviews in seven countries with a variety of Global Fund stakeholders An in-person consultation in São Paulo, Brazil over 28 – 30 June 2011 These consultations are being undertaken at an important time for the Global Fund and its constituencies. They coincide with and inform the implementation of a reform agenda for a more ef cient and effective Global Fund. The reform areas identify areas where changes to the Global Fund’s business model will support even greater impact in the future. Simultaneously – and interconnected with the reform agenda – the Global Fund’s Board is developing a new Strategy for the period 2012 to 2016. A key focus of the Board’s deliberations is how the Global Fund’s resources can be better leveraged within the scope of the three diseases to have even more impact on the health related Millennium Development Goals. The 2011 Partnership Forum consultations present a key opportunity for broad, participatory input on the Strategy – to build on the Strategy Framework that was considered by the Global Fund Board in May 20111. This report summarizes what respondents to the e-Forum and the e-Survey said, in two parts: 1. Part I: Summaries from the three separate topics discussed over the multi-language e-Forum. The summaries capture contributions from e-Forum discussants, grouped by the three topics discussed; and 2. Part II: Analysis of the 2011 Partnership Forum e-Survey responses. Survey data is collated and presented under the ve sub-themes of the 2011 Partnership Forum, highlighting broader feedback on measures for improved clarity and effectiveness in all that we do. Published in mid June 2011, this Report is intended to serve as an important input into the in-person consultations in São Paulo, and therefore, the future Strategy of the Global Fund. Due to the quality and extensive quantity of information collected, further analysis will be undertaken after the São Paulo consultations to ensure the suggestions made and opinions expressed are fully utilized. Further analysis will also be done on the survey data to look in depth at the correlations, for example to show regional trends and differences and to show differences between type of organizations and what they expressed. This data will be used by the Global Fund to inform its programming and function as it moves towards implementing its new ve-year Strategy.

1 Refer to http://www.aidsportal.org/web/globalfundconsult/documents for the Draft Strategy Framework acknowledged at the Global Fund’s Twenty-Third Board Meeting in May 2011.

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BACKGROUND AND METHODOLOGY
ONLINE SURVEY
For the Fourth Partnership Forum in 2011, as part of the on-line consultation, the Global Fund commissioned an online survey to seek views from all constituencies on the future direction and operations of the Global Fund (e-Survey). The objectives of the e-Survey were to: Understand the concerns and views of Global Fund constituencies, including those who are interested but have not yet been able to engage with the Global Fund. Give diverse constituencies the opportunity to input into the ongoing evolution and work of the Global Fund Provide an opportunity for partners to input into the 2011 Partnership Forum Inform strategic discussions and direction of the Global Fund

MULTI-LANGUAGE E-FORUM DISCUSSIONS
Complementing the online survey were moderated e-Forum discussions, also in four languages, that sought to dig deeper on three topics identi ed by the 2011 Partnership Forum Steering Committee: Lives saved and value for money Human rights Strengthening country-level partnerships

COUNTRY-LEVEL INTERVIEWS
In addition, Key Correspondents (KCs)2 interviewed Global Fund stakeholders in Indonesia, Dominican Republic, India, Thailand, Zimbabwe, Kenya and Russia and produced a series of articles (written and video) showing perspectives from the different countries. Feedback from the KCs has been produced as an independent report of the KCs. The country-level articles and more detailed reports of the e-Forum discussions are all available at: http://www.aidsportal.org/web/globalfundconsult/documents

2 For more information about the KC team visit: http://www.aidsalliance.org/Pagedetails.aspx?id=466

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PART I: MULTI-LANGUAGE E-FORUM DISCUSSIONS
Part I of this document presents selected ndings from the e-Forum discussions that took place in English for English speakers, in Spanish for the Latin American region, in Russian for the Eastern European and Central Asian region and in French for the West African region, in which 3390 members took part. As already noted, a Chinese language e-Forum discussion is underway, and the results will be included in a nal on-line report. During a six week period over 575 comments were posted on e-Forums in four different languages (407 in English, 26 in Russian, 121 in Spanish and 21 in French) from more than 79 countries from every region of the world. They included:
Afghanistan, Argentina, Azerbaijan, Bangladesh, Belarus, Belize, Bhutan, Bolivia, Brazil, Brunei Darussalam, Cambodia, Cameroon, Canada, Chad, Colombia, Costa Rica, Côte d’Ivoire, Cuba, Democratic Republic of Congo (DRC), Dominican Republic, Ecuador, El Salvador, Ethiopia, Fiji, Gambia, Georgia, Ghana, Guyana, Guatemala, India, Indonesia, Italy, Jamaica, Jordan, Kenya, Kyrgyzstan, Laos, Liberia, Malaysia, Mexico, Mozambique, Myanmar, Namibia, Nauru, Nepal, New Caledonia, Nicaragua, Niger, Nigeria, Pakistan, Panama, Paraguay, Peru, Philippines, Portugal, Republic of Yemen, Romania, Russia, Samoa, Saudi Arabia, Sierra Leone, Singapore, South Africa, Sri Lanka, Sudan, Syria, Tajikistan, Tanzania, Thailand, Tunisia, Uganda, UK, Ukraine, United Arab Emirates, USA, Vietnam, Yemen, Zambia and Zimbabwe.

The document is organized according to the three e-Forum topics, as agreed by the 2011 Global Fund Partnership Forum Steering Committee. Each topic is presented in the format ‘We asked…, you said…’. Lives saved and value for money Addressing human rights in country settings Strengthening country-level partnerships and alignment The document is not a summary of the extensive discussions and in-depth contributions made in the 575 postings received, but rather a selection of key themes, supported by participants’ own words, to express some of the issues, recommendations and opinions shared. Participants’ own words are denoted using quotation marks, and (Sp) (Ru) and (Fr) after a quotation indicates a contribution from the Spanish, Russian and French e-Forum discussions.

Further documentation In addition to this short document presenting key themes, a number of important documents are available on: http://www.aidsportal.org/web/globalfundconsult/documents that present more in depth summaries of each topic on each e-Forum as well as a complete archive of postings. These include: Topic 1 Summaries: Lives saved and value for money – from English, Spanish, Russian and French e-Forums, each available in four languages Topic 2 Summaries: Human rights – from English, Spanish, Russian and French e-Forums, each available in four languages Topic 3 Summaries: Strengthening country-level partnerships from English, Spanish, Russian and French e-Forums, each available in four languages Latin American Regional Report: Highlighting key issues and recommendations, summarizing all discussions from the Spanish e-Forum – available in Spanish and English Four documents comprising complete archive of all postings received acknowledging all contributions Some of the limitations with this approach included: Participation was limited only to those with reliable internet access Short time-frame: each topic was discussed for only two week Active participation from Russian and French e-Forums was considerably less than English and Spanish “Thanks to the Global Fund Consultation Team for initiating the e-discussions. It seems to be a productive approach which will provide opportunities for people from different strata to express their views as well as to share their experience with regard to Global Fund and its programmes”, e-Forum participant, May 2011

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LIVES SAVED AND VALUE FOR MONEY

“Our largest opportunities to improve human health do not lie in optimizing services to the 20% of people in the developing world currently reached by health systems – they lie in extending our reach to the 80% who lack access to health facilities”
WE ASKED…

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YOU SAID…

HINKING ABOUT WHAT IT FUNDS AND THE WAY FUNDING IS CURRENTLY PROVIDED, WHAT SHOULD THE GLOBAL FUND DO MORE OF – OR LESS OF – IN ORDER TO MAXIMIZE VALUE FOR MONEY AND INCREASE THE NUMBER OF LIVES SAVED AND INFECTIONS PREVENTED?

Sustainability and alignment with national strategy and systems
Participants commented on the importance of building capacity and strengthening community and health systems to achieve long-term sustainability as well as the need for better alignment with national responses and systems at all levels. “When grants come to an end, we still lack public policies that ensures long term sustainability of the programs. We’re not taking advantage of having those grants” (Sp) “There is no self suf ciency for an orphanage (not unless you can stomach child labour). They are a long term, continuing commitments” “We need to urge the CCM to present a speci c plan for transferring to the governmental systems and to nd more synergies, as part of the proposal, with a clear and critical roadmap to follow and activities that can be monitored”. (Sp) “Enable recipient countries to develop ownership of the Global Fund mechanism to make it theirs. In our view, only the degree of ownership will guarantee the investments made”

Linkages with broader health issues and strengthening of health and community systems
Participants discussed ensuring stronger health and community systems that strengthen the important linkages between HIV, malaria, TB and other health issues clearly emerged as a way of increasing the impact of Global Fund investments on reducing disease burden. “One other signi cant strategy of the Global Fund that maximizes value-for-money is its willingness to invest in Health Systems Strengthening (HSS). This single strategy will have system-wide effect on not only HIV, TB and malaria as an integrated disease management program, but also on integrated maternal and child health (IMNCH), immunization, nutrition and many other areas” “Look at other co-morbidities and co-infections people living with HIV deal [with] in our countries. For example, funding collaborative programme activities beyond TB and HIV, like those for hepatitis C (Hep C or HCV), diabetes, cancer, renal or kidney related diseases, nutrition and other areas that impact the health of people living with HIV and AIDS”

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“From my own experience, I want to ask the Global Fund to ght AIDS, TB and Malaria to support and partner with nutrition programmes so that people who are seeking anti-TB treatment are bene ted with nutritional support. TB drugs are so toxic and our small breakfast of a ‘pao’ (bread) is possibly not enough to help us deal with strong medicines” “I suggest to the Global Fund to broaden its scope to other issues in major public health including cancers whose treatment is extremely costly and prevention dif cult. They are becoming more frequent and causing havoc and major trauma in Cameroon, in particular and Africa in general” (Fr) “a quality blood safety program will have a direct effect on the Millennium Development Goals (MDGs) 4, 5, and 6 vis-a-vis improvement in child health, reduction of maternal mortality and reduction in the spread of HIV” “reduce child mortality rate and improve the maternal health in an effort to meet the millennium development goals (MDGs) 4 and 5”

Better quality prevention, care, treatment and support services
Participants commented on the need for quality interventions that support the increased effectiveness of services, highlighting the need for equal attention on prevention as well as treatment. Sustainability and continuity of services was stressed, as was the need for equal attention to qualitative and quantitative indicators that evaluate quality services.

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“In itself, increasing the number of lives saved should not be the main result and indicator for the Global Fund. Issues of service quality, issues of prevention are much more important in the future perspective” (Ru) “In order to save more lives we need to reduce government bureaucracy. A better and speedier system for drug procurement; cost-bene ts of second and third lines of drugs when negotiating prices; promoting joint acquisition with neighboring countries and having the support of the UN for drugs procurement” (Sp) “I will like to add that prevention, treatment, care and support services for transgender (TG) living with or at risk of HIV are very poor, unfriendly and therefore underutilized” “Prevention is more cost effective than curative strategies. Fund should invest more on applied research” “Even though youth are part of the communities receiving treatments, in many times there are no speci c focus and youth friendly services available” “The Global Fund has generally failed to address the needs of ethno-linguistic minorities in the Mekong Region that are disproportionately impacted by HIV. The log frame mentality is the death of thought and sometimes the death of people” “The Global Fund should focus more on income generating projects to better the quality of people living with HIV and AIDS.” “The programs supported by the Global Fund should develop Civil Society-led community health services centres that will contribute to Universal Access” (Sp)

Accountability and nancial oversight
Participants discussed the challenges of ensuring accountability to communities and oversight of funds, suggesting ways they could be improved. This included suggestions for improved monitoring of high-impact indicators, a greater regional presence of the Global Fund Secretariat and strengthening of an oversight role with improved monitoring of transparency and ethics of CCMs. “CCM secretariats, if empowered to take critical steps towards successful programme implementation will go a long way in checking the excesses of the PRs, and also reduce logistic expenditures by the Global Fund on LFAs, Global Fund Country teams, the OIG etc” “The Global Fund should only enter partnerships for the right reasons rather than because it is politically expedient to do so. While it could be argued that to ignore political imperatives would jeopardise future funding, it won’t. If donors want to cut funding they will always nd an excuse but it would be far better to stick to our founding principles than be so willing to set them aside” “Global Fund has a social responsibility, and equity and justice should be contemplated in the distribution of funds. Countries that spend millions on war instead of investing in health should be penalized in the distribution of funds” “If in the development and design of plans, programs and projects there is a proper involvement of all the stakeholders (affected communities, governments, academia, civil society, etc.), we will achieve more democracy. If in the life of the program you have a strong monitoring and evaluation system led by the CCM, the PR and the affected communities, then you will be able to play a better watchdog role” (Sp) “More time is spent by the Global Fund recipients on measuring and reporting on the grants than on actual programme delivery. Besides extremely stringent nancial procedures end up compromising the quality of programmes delivered due to a lot of time and attention being paid on ensuring value for money” “Fraudulent of cers or actors who have embezzled the Global Fund money at national level should be brought to book and the money recovered”

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“To increase the effectiveness of assistance and save more lives, funding must be spent for its intended purpose, and be allocated where it will really bring help” (Ru) “Develop regional representations for a better follow-up of interventions and fund management” (Fr) “The Global Fund should increase the control over government recipients, closely oversee them, in order to increase ef ciency, especially in something so sensitive like ARV procurement” (Sp) “In my opinion, the ef ciency of utilization of nancial resources provided by donor agencies has signi cantly reduced due to the in uence of two main factors: 1. Provided by foreign donors, including the Global Fund, the funds are not always directed to the priority areas. 2. A large part of nancial resources goes through corruption schemes, caused by the lack of honesty, including among some NGOs” (Ru) “The Global Fund hasn’t become a “fresh wind”, but one of the “dragons” who sit on humanitarian aid, annually increasing their own costs on the content itself”. (Ru) “Leadership and management at all levels of implementation of Global Fund Programs need to be required and clearly proposed in applications for funding and development of practical leadership and management skills are needed in all areas of implementation” “The Global Fund should discuss a full review of the CCM model and a redesign of this governance structure, and put in place mechanism to reduce con ict of interest and increase the oversight role” (Sp)

Better quality communication and access to information
Participants highlighted weaknesses in communication, access to and quality of important information as well as a lack of understanding of how to feed concerns into the Global Fund. “We need to ensure equal access to information on Global Fund policies and programs so all Civil Society groups (mainly those of MARPs) will have real chances to participate and access the Fund. The Global Fund related information should be available in our languages” (Sp) “Often, representatives of civil society and the community do not know how they can forward their concerns and suggestions to the Global Fund. In many communities, there is insuf cient information on the delegations to the Global Fund Board, delegates representing their interests, and no understanding of the Global Fund processes and mechanisms” (Ru)

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ADDRESSING HUMAN RIGHTS IN COUNTRY SETTINGS

“Vague promises of anti-stigma campaigns are no substitute for solid programming to keep people from being hurt, degraded, and detained or imprisoned without cause or recourse”
WE ASKED…

W
YOU SAID…

HAT CHANGES CAN THE GLOBAL FUND MAKE TO ITS MODEL TO ADDRESS BARRIERS IN THE DELIVERY OF EVIDENCE-BASED SERVICES TO MOST AT RISK AND OTHER UNDERSERVED POPULATIONS – IN A WAY THAT PROTECTS HUMAN RIGHTS AND PREVENTS VIOLATIONS?

Stronger commitment to human rights and actions to reduce discriminatory laws
Participants expressed the desire to see a strong commitment to human rights re ected in Global Fund proposals, programs and indicators and also by the development of a Global Fund Strategy on Human Rights. They clearly commented on the need to reduce discriminatory laws and norms that present one of the main barriers to scaling up effective prevention, care, treatment and support services for affected communities. Participants also clearly recommended the Global Fund promote and support the Patients’ Charter for TB Care. “The Global Fund should ensure that country programs include human rights interventions in its proposals and promote law reforms and policy changes that target most at risk populations. This is the only way to achieve an impact in the epidemic and in the lives of people” (Sp) “This could include an analysis of how much money is going to services like legal aid, and clear plans on how the country will respond when the police round up sex workers and forcibly test them for HIV or announce quotas for drug users to be sent to labour centres and do wholesale urine testing of people they nd outside a needle exchange” “The benchmark of Global Fund’s success lies not merely in making the drugs available but the care, warmth and dignity these are wrapped in” “In our opinion, the Global Fund should develop a strategy of working with IDUs which will clearly state all Global Fund policies and approaches for working with this group as well as approve a plan to implement this strategy” (Ru) “HIV-positive women, young women, girls and adolescents face stigma and discrimination, which result in various consequences: job or property loss, lack of access to nutrition and/or training, rejection by the family or close relations, violence or life at risk. All those conditions, related to different people, must be addressed in designing programs. A human rights and gender-based approach and perspective is critical to ensure total and effective universal access to rights by women, young women, girls and adolescents living with HIV and AIDS. Thus, programs should address the actual needs of this group” (Fr) “Violations of human rights are the very root of all evil, from which stem the increase in infectious disease cases, deaths from overdoses and other consequences of drug use, failure to communicate with social services, retreat of clients into the shadows, and criminalization, to which one must pay the utmost attention,” (Ru)

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“The violation of the human rights of those most at risk and other marginalized populations in our region is closely related to poverty and extreme poverty” (Sp) “The Global Fund should control that country programs include Human Rights interventions in its proposals and promote law reforms and policy changes that goes against most at risk populations. This is the only way to achieve an impact in the epidemic and in the lives of people” (Sp) “Current service coverage is very low for men who have sex with men (MSM) and this situation needs to change. It is a human rights issue because after so many years, we still are dealing with abysmally low service coverage” “Without attention to human rights, Global Fund nancing allocated to Highly Active Antiretroviral Therapy (HAART), harm reduction and support for access to these programs is less than is needed to make a real impact on the spread of HIV. To work more effectively, Global Fund programs should have more focus on human rights.” (Ru) “It is a human rights issue to provide reproductive health services for female injecting drug users (IDUs) – the stigma in general healthcare services is alarmingly high – and a friendly, safe and supportive healthcare service facility for female IDU is a rare nd” “If we talk about components of working with IDUs that should be determined and formalized in a Global Fund policy, it is hepatitis C, overdose prevention and opioid substitution therapy (OST)” (Ru) “After drug users have been rejected for treatment of abscesses and/or treatment of tuberculosis and HIV, they lose con dence not only in professionals from one sphere, but in people in general, preferring next time to solve their problems by themselves.” (Ru)

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Meaningful engagement of most-at-risk populations
Participants from all regions commented on the importance of increasing meaningful participation of most-at-risk-populations in CCMs. They also commented that inclusion of voices of people living with and vulnerable to HIV should be a requirement in all HIV funding applications. “In order to overcome health services barriers the Global Fund funded programs should increase the Key Populations involvement at the implementation and monitoring level. Communication material and service facilities needs to be more friendly and accessible” (Sp) “No health services can work if people are afraid that using them will expose them to police violence, arrest, harassment, discrimination, or cruel, inhuman or degrading treatment” “Representatives of vulnerable groups, including injecting drug users, need to participate meaningfully in the Global Fund at all levels of its architecture, from the country CCM to Delegations to the Global Fund board. The voice of the community should be heard, so that the community can participate directly in shaping policies for work with the groups they represent” (Ru) “One signi cant barrier for access of vulnerable groups is the low level of legal awareness among vulnerable groups themselves” (Ru) “The Global Fund should require that more civil society and key populations representative are part of the CCM, currently in my country the CCM membership doesn’t re ect our needs” (Sp) “I think that human rights are the basics of response to the epidemics. Prevention should be expanded with a focus on vulnerable groups, coverage with treatment of these groups should be improved”. (Ru) “Unless the gender-based inequalities and structural changes in communities from patriarchal to a more human setup happens women will continue to be the last to access services. Partnering with groups that are addressing women rights’ issues will give more value for every dollar spent and increase take up of services among women” “Although within the Global Fund program “Human rights and HIV” [where] people were taught [about] the rights and how to protect them, people have not learned to apply this knowledge in relation to themselves” (Ru) “One of the major challenges in TB and HIV/AIDS control in our country I consider the lack of attention to people released from prisons”. “All agree that ex-convicts are a priority target group, but there is absolutely no attention given to mobilize these resources and bring them to solve problems relating not only to themselves but also to society as a whole” (Ru)

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No support to programs that violate human rights
Participants described – often using speci c examples – how the Global Fund may inadvertently be funding interventions that violate human rights of vulnerable populations. They commented on the need to take opportunities to actively promote human rights. They also emphasized the importance of decriminalization of drug users, sex workers and other most-at-risk populations. “I think as much emphasis should be put on making sure that human rights are respected in Global Fund-funded programs as is put on fraud prevention. Similar structures should be set up to vet all proposals for minimum human rights protections, and governments should not be allowed to keep funds away from lesbian, gay, bi-sexual and transgender groups because programs are ‘country driven’, for instance. An important issue is the potential use of Global Fund funds to pay for forced sterilization procedures in women living with HIV. Procedures for informed consent should be universal and mandatory for receipt of funds” “The Global Fund grants are being used in numerous countries in Asia (and probably other regions as well) for programmes that violate basic human rights and accepted universal ethical standards in healthcare. The funding of compulsory detention centres for drug users and sex workers is one example. The other things we see over and over in sex work programming is compulsory or highly coercive testing – for STIs and HIV. Compulsory testing of sex works is not only driven by government policies which ignore human rights – but is also being driven by the Global Fund indicators which give programmes ridiculous targets of the number of sex workers (or MSM or IDUs) who must be tested in order to meet monitoring and evaluation targets. This not only violates the rights of sex workers and others, but in many cases it wastes huge amounts of money doing repeat tests for people who really don’t need testing. These results are then not kept con dential – they are, in many cases, shared with sex business owners and needlessly shared among staff of implementing organisations” “Look at the ‘shame parades’ police subjected sex workers to in China (the Global Fund was supporting outreach to this population), the reports of police rape and abuse of men who have sex with men in Uzbekistan (the Global Fund was supporting outreach to this population), or the harassment of patients and providers of methadone in Ukraine, (the Global Fund was supporting methadone programs)” “Criminalization leads to marginalization and discrimination. Along with this, harm reduction, substitution treatment and overdose prevention have insuf cient coverage and are arti cially constrained, or are banned” (Ru) The Global Fund should make sure that it’s not harming and giving legitimacy to practices or governments that are openly abusive of human rights of most-at-risk populations. “China, Zimbabwe, Myanmar, and North Korea, all countries that have received Global Fund support, come to mind”

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IMPROVING COUNTRY-LEVEL PARTNERSHIPS AND ALIGNMENT

“Open, simple and practical communication solutions is also a key in making partnerships work at all levels”
WE ASKED…

W
YOU SAID…

HAT ARE THE WAYS THE GLOBAL FUND CAN STRENGTHEN THE EFFECTIVENESS OF ITS COUNTRY-LEVEL PARTNERSHIPS TO IMPROVE OUTCOMES AND IMPACT FOR THE THREE DISEASES?

Reinvigorating Partnerships
Partnerships require real collaboration and coordination, not just meetings. Many participants described weaknesses not so much in the model itself, but in how it is being implemented. The issue of community voices being present in various partnerships – but not necessarily heard – was raised repeatedly. “To be able to strengthen country partnerships we need to have a central mechanism that brings all the stakeholders to one platform of planning, budgeting and implementation phases for the 3 diseases” “Country-level partnerships should make sure that louder voices don’t dominate – and – they are truly driven by the communities even if governments and big NGOs and donors are a part of it” “Usually the bene ts of Global Fund programs only reach our capital or bigger cities, with a very low impact in small town in the provinces. We don’t have data on the rural epidemic and we lack nancial human resources in these places far away from the main cities” (Sp) “In order to achieve better alignment and partnership you need to start by having a real national situational analysis which is evidence-based, allowing us to identify the gaps and needs in the disease programs at government and civil society level. We need to have a comprehensive national plan built with a meaningful participation of all the sectors” (Sp) “Partnerships work only when members agree on a common agenda rising above and beyond their organisational agendas at times. If we limit ourselves to our organisational mandates only, then partnerships are likely to suffer” “For better results, expert organizations working with the Global Fund should share their experiences with young organizations, and should not be competitive with each other” “The lack of coordination and alignment is the result of lack of government commitment and civil society interest and resources. The multisectoral work happens only due to the existence of CCMs” (Sp) “For a coordinated response at a country level on HIV, TB and malaria it is important for the issue-speci c partnerships to coordinate with each other and also directly feed into CCMs, if not drive CCMs. Without a common shared agenda for advocacy and action, it will be more dif cult” “Even government ministries and departments struggle for inter-sectoral collaboration – it is not so easy to facilitate a multi-stakeholder partnership and hope for a horizontal approach. Unless at policy level intersectoral collaboration is laid down with indicators to monitor and evaluate it, it will be a long road ahead”

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“Based on the experience of Belarus, I would like to draw attention to the issue of cross-sectoral partnerships. At various levels, this partnership is not prioritized as a mandatory requirement for implementation of project activities.” (Ru) “Involvement of NGOs and AIDS community-based organizations, as well as experts from among them, into implementation of TB programs, taking over their experiences and methods of work with target groups (outreach work, hotlines, social support etc) can contribute into the effectiveness of grants implementation” (Ru) “For a coordinated response at a country level on HIV, TB and malaria it is important for the issue-speci c partnerships to coordinate with each other and also directly feed into CCMs, if not drive CCMs. Without a common shared agenda for advocacy and action, it will be more dif cult”

Real Partnerships for effective implementation and results:
Participants described ongoing challenges with the meaningful engagement of civil society, in particular most-at-risk populations in the CCMs and voiced concerns over how civil society will be engaged in the development of National Strategy Applications. Participants also highlighted the need to engage nontraditional stakeholders such as other Ministries in addition to Ministries of Health in CCMs. “We also have to stop thinking that civil society cannot do the work properly” “If we speak about the situation in Kyrgyzstan, then it’s early to speak about the existence of partnerships. It must be noted that having UNDP as Principal Recipient is far from recognizing national structures as equal partners” (Ru) “Real action if any has, and will, come at local level. That is where a partnership can make a real difference” “Community Systems Strengthening (CSS) develops and strengthens community-based organizations so that they can achieve improved health service delivery” “It is possible to improve country partnerships and coordination of activities with more effective policies to involve community members in the resolution of existing problems related not only to themselves, but to society as a whole in terms of ghting against the epidemic of TB and HIV/AIDS,” (Ru) “I believe that the Global Fund has contributed to better organization of our work. In relation to NSA there isn’t suf cient clarity from the Global Fund on what a National Strategy means. When we request external nancial support from Global Fund it does not necessarily mean that we have a good national disease strategy, that’s why we’re asking for support” (Sp) “The implementation, particularly holding the development partners to their commitment to country ownership and host-country determination of what they need could also be chaired through the CCM. However, the role of civil society implementers and drawing on in-country experience of past and continuing implementers could be a simple form of country-level partnership that aid transparency and strengthen implementation”

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Managing partnership funding – both a challenge and an opportunity.
“Even without money, voluntary partnerships of civil society or diverse stakeholders are never easy to manage. With money things can become more dif cult if we are not careful. It is a double edge sword” “Leaving CCM to source funding from the Government and unwilling partners is unhealthy. Until wellde ned sources of funding for the CCM are well entrenched, the principle of equality of membership will remain a challenge to CCM partnership”

Improved monitoring and evaluation
Participants highlighted the need for improved and collectively developed monitoring and evaluation systems that go beyond the Global Fund performance framework so that medium and long-term objectives, indicators and targets align with national systems. “the Global Fund needs to strengthen countries improve their monitoring and evaluation frameworks especially strengthen consultations with stakeholders and bene ciaries of each program and at all levels” “Global Fund should devote equal attention to quantitative and qualitative indicators and implement measures to set the priorities of different problems” (Ru) “Monitoring and evaluating CCMs should also be a part of the rigorous process the Global Fund adopts” “If in the life of the program you have a strong monitoring and evaluation system lead by the CCM, the PR and the affected communities then you will be able to play a better watchdog role” (Sp) “Harmonised monitoring and evaluation (M&E) indicators for all diseases is an area that requires joint partner actions and CCMs may need support to be able to do that”

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PART II: ONLINE SURVEY
After providing analysis on respondents to the e-Survey, Part II of this Report presents ndings from the e-Survey selected3 for their particular relevance and alignment to the ve topics identi ed by the 2011 Partnership Forum Steering Committee as important contributions to the evolving new Global Fund Strategy. 1. Who are the survey respondents 2. Overall direction and strategy of the Global Fund 3. Maximizing impact: Using investments in the three diseases to deliver broader health outcomes within community and national health systems 4. Delivering on a human rights approach for the three diseases: Where should this take us? 5. Using the money wisely (1): Funding the right things 6. Using the money wisely (2): Strengthening governance and oversight to get it right 7. Implementing for increased impact 8. Innovation Each of the above listed sections begins with a brief commentary on the issue and a short description of the e-Survey responses relevant to that section, followed by speci c survey results. The results presented here should be read as indications of trends based on broad-based opinions. This was not a research project and the data should be used to provoke and stimulate ideas for further investigation rather than as evidence. As not all the e-Survey results are presented in this document, a separate document containing all quantitative survey responses is available at: http://www.aidsportal.org/web/globalfundconsult/documents The survey was designed in English and programmed using Survey Monkey. It was translated into Spanish, Russian and French and promoted widely using existing HIV, tuberculosis and malaria networks as well as Global Fund Secretariat contact lists. 1279 people responded from 174 countries, 1039 in English, 109 in Spanish, 39 in French and 92 in Russian. The survey consisted of 41 questions and was designed around the following headings: 1. 2. 3. 4. 5. 6. 7. Introduction Respondent information Principles and mandate Implementation and results Constituency engagement and governance Oversight and Accountability Innovation for Impact

As with all projects of its kind, there are limitations. In particular, some of the limitations included: Short time frame may have limited the number of responses. Shorter timeframe for French and Russian due to time required for translation may have further limited responses in these languages. As an online survey, participation was limited only to those with reliable internet access. The questionnaire was relatively long and complex, requiring a certain level of understanding of the Global Fund. Early feedback from respondents suggested some questions could have been worded more clearly, and initial problems with two questions were quickly adjusted. The variation in respondent numbers across regions and sectors means that any cross-regional or cross-sectoral analysis remains speculative and would require further investigation.

3 Refer to Section above ‘The Partnership Forum e-Consultations: Your voice and the Global Fund Strategy’ for information the intended publication of additional information to inform other aspects of the Global Fund’s work

16

HIGHLIGHTS OF E-SURVEY RESPONSES
Overall the survey presented a positive picture in terms of the effectiveness and impact of the Global Fund at the country level. The survey respondents represented all sectors, regions and constituents so the responses provide a diverse and multi-faceted perspective that is seldom possible to gather on such a large scale. While bearing in mind the small number of respondents in some regions and sectors, the divergence in views nonetheless suggests that the Global Fund and its constituents face a continuing challenge of managing diversity and con ict over approaches and priorities in many areas. These include the “right” allocation of funding across the three diseases, the degree to which the Global Fund is successfully addressing the needs of key affected populations, and whether or not the Global Fund has done enough to strengthen community-level capacity. There is very strong agreement that the Global Fund’s existing principles remain relevant, but there is a view among several respondents that a principle clearly addressing human rights is lacking. One respondent commented that “I think as much emphasis should be put on making sure that human rights are respected in Global Fund-funded programs as is put on fraud prevention.” Several respondents also called for greater exibility in the Global Fund’s application of its model, to acknowledge and be more responsive to different country contexts. The high level of regional variation in responses to many questions further supports the potential relevance of this suggestion. There was very strong agreement among respondents that the Global Fund should sustain its commitment to the engagement of non-government sectors at the country level as it rolls out new funding channels, including National Strategy Applications and the Health Systems Joint Funding platform. In addition to the structured survey questions, a nal open-ended question asked respondents to suggest any innovations that could enable the Global Fund to have greater impact. Many comments were in the form of recommendations to improve the functioning of CCMs and other aspects of the current model, and provide ideas that can now be fed into the Global Fund Partnership Forum, the development and implementation the Global Fund strategy, and the Global Fund Comprehensive Program for Reform.

17

RESULTS
WHO RESPONDED TO THE SURVEY?
Out of 1279 respondents, 61% were male, 38% were female and 1% transgender. 31% of respondents were aged 22-34, 32% aged 35-44, 23% aged 45–54 and 11% aged 55–64. 2% were under 21 and 3% over 65. Responses to the survey were received from 174 countries spanning all regions of the world. The regional breakdown of responses is provided in Chart 1. Respondents came from a wide range of sectors re ecting the diversity of the stakeholders interested and currently engaged in the Global Fund all over the world.

Chart 1: Region (n=1279)
East Africa and Indian Ocean 6% East Asia and Paci c 11% Eastern Europe and Central Asia 12% Europe and North America 25% Latin America and Caribbean 14% Middle East and North Africa 2% South and West Asia 14% Southern Africa 6% West and Central Africa 10%

6% 10% 6% 12% 11%

14% 2% 25%

14% 0.3% 0.3% 3% 3% 4% 4% 4% 12% 2% 2% 16%

Chart 2: Sector (n=1265)
Developed Country / International NGO 16% Other 12% Academia 10% Developing (Recipient) Country NGO 10% Communities (NGOs representative of the Communities Living with the Diseases) 9% Person living with or affected by HIV, TB or malaria. 8% Community Based Organization 8% Developing (Non-Recipient) Country NGO 5% Multilateral Partners 4% Recipient Country Government 4% Business / Private Sector 4% Donor Government (Bilateral Partner) 3% Foundation 3% Global Fund Secretariat 2% Faith-Based Organization 2% Employee Association or Trade Union 0.3% Member of Parliament / Working with Members of Parliament 0.3%

5% 10%

8% 10% 8%
9%

18

As well as sector, many respondents speci ed which population groups they were a member of or represented. Those representing women and girls, men who have sex with men, people living with HIV and youth made up the largest proportion and those representing refugees, migrants and prisoners the smallest proportion. For those respondents who selected “other”, most responses identi ed speci c sectors rather than population groups.
1.5% 2.2%

1.2% 0.3% 24%

Chart 3: Population Groups (n=946)
Women and girls 24% Other 20% Men who have sex with men 15% People living with HIV 13% Youth 10% Youth / Most at risk population 7% People who inject drugs 3.4% Vulnerable children and orphans 3.4% Male, female and transgender sex workers 2.2% Transgender persons 1.5% Refugees and migrants 1.2% Prisoners 0.3%

3.4% 3.4%

7%

20% 10%

13% 15%

For those representing an organization, respondents also identi ed how they were engaged with the Global Fund. 23% of respondents identi ed themselves as principal or sub-recipients, 11% as advocates, 10% as Country Coordinating Mechanism (CCM) Members and technical assistance providers respectively, and 8% as Board or Committee members. 18% of respondents were not directly engaged with the Global Fund.

10% 11% 8%

Chart 4: Global Fund Engagement
CCM Member 10% Board or Committee Member/Alternate 8% Principal Recipient 11% Sub-Recipient 12% Sub-Sub Recipient 9% Technical Assistance provider 10% Advocate 11% Not directly engaged 18% Other 11%

11%

18% 12%

11% 10% 9%

19

OVERALL DIRECTION AND STRATEGY OF THE GLOBAL FUND
86% of survey respondents said the principles of the Global Fund were still relevant. When asked, 40% commented that key principles were missing. While many comments were made about key principles that were missing, the most common view was that a principle that clearly focuses on human rights is missing.

GLOBAL FUND PRINCIPLES AND HUMAN RIGHTS Eliminate support of programs that violate human rights or inadvertently contribute to human rights violations Focus on equity and improved access for the most vulnerable Achieve equal representation in CCMs of most-at-risk populations Ensure strong consideration of human rights elements in proposals OTHER SUGGESTIONS Many other comments to the question on principles made suggestions for expanding and strengthening the wording in the existing principles as well as suggestions for how the Global Fund can improve how the principles are put in to operation. These suggestions are particularly relevant in the context of the Global Fund’s Comprehensive Program for Reform that is being implemented throughout 2011. They included the following: Anti-corruption Strengthen anti-corruption and risk management to ensure greater accountability and appropriate use of funds Decreased political in uence and bureaucracy Evidence-informed programming Funding based on quality of evidence-based programs Indicators that better re ect balance of qualitative and quantitative, nancial and non- nancial Country-context exibility Country-led nancing mechanisms need to be developed and strengthened, allowing for exibility of funding channels based on context, and reducing the need for the Global Fund to establish and fund new mechanisms. Country ownership and alignment with national systems is not appropriate for all countries, some countries need humanitarian-type assistance and the Global Fund model is not conducive to performance in this context Improved involvement of the Global Fund to increase technical assistance and economic development in the situation of crisis and transition. Community participation and national ownership Building capacities of local implementing partners and communities to ensure local ownership, training grassroots in self-management and monitoring and evaluation. Encourage national and sub-national health system strengthening and anti-corruption policies to improve national ownership and capacity Bene ciary accountability and feedback from communities

Chart 5: Global Fund Principles still relevant? (n=1037)

14% No

Yes 86%

20

Funding allocation Allocate funding based on “know your epidemic”/ attention to epidemiology Improvement in equitable funding amongst the three diseases, currently too much on HIV More integration and linkages to other health issues such as reproductive health, maternal health, sexual behavior Focus on prevention in areas that warrant greater attention to stigma and discrimination Sustainability A principle focused on strengthening of health systems and staff, so as to support the sustainability and self-suf ciency of initiatives against the three diseases for the long term. Global Fund should clarify how it removes itself from directly driving grant implementation and funding The sustainability of funding depends not only on the Global Fund but also on the economic climate and national debts and budgets; this makes the involvement of the Minister of Finance vital as a key nancier of inputs and services that exceed the nancial limitations and institutional constraints on domestic government.

UNDERSTANDING THE GLOBAL FUND Encouragingly, over 78% of survey respondents said they understood the processes of the Global Fund. In addition, the fact that almost 1300 people were able to complete the survey in itself, which required a good understanding of the Global Fund, suggests that it is well understood.

3% 11% 28%

Chart 6: How well do you feel you understand the processes of the Global Fund? (n=822)
Extremely well 11% Very well 28% Moderately well 39% A little 19% Not at all 3%

19%

31% of respondents answering the question ‘ten years after its establishment what should the Global Fund focus on’ said the Global Fund should increase attention to ensuring the quality of the interventions that are funded. 25% said the Global Fund should continue to focus rst on increasing the number of lives saved. 24% said the Global Fund should increase attention to epidemiology to ensure that the only proposals that are funded are those that re ect a ‘know your epidemic’ analysis and address the most affected populations in a country. 20% said attention to human rights should be increased even if it means reaching lower total numbers of people. Respondents could choose more than one option.

39%

25%

Chart 7: Ten years after its establishment, the Global Fund now needs to:
Continue to focus rst on increasing the numbers of lives saved 25% Increase attention to ensuring the quality of interventions that are funded 31% Increase attention to epidemiology to ensure that the only proposals that are funded are those that re ect a “know your epidemic” analysis and address the most affected populations in a country 24% Increase attention to human rights even if it means reaching lower total numbers of people 20%

20%

31%

24%

21

MAXIMIZING IMPACT: USING INVESTMENTS IN THE THREE DISEASES TO DELIVER BROADER HEALTH OUTCOMES WITHIN COMMUNITY AND NATIONAL HEALTH SYSTEMS
Health and community systems are at the core of all responses to HIV, tuberculosis and malaria. All investments made in HIV, tuberculosis and malaria have a wider impact on health and community systems. Evidence demonstrates that there are important links between the health-related Millennium Development Goals (MDGs) – MDG 4 (reduce child mortality), MDG 5 (improve maternal health), and MDG 6 (combat HIV/AIDS, malaria and other diseases). Increasing the impact of Global Fund investments on other health services, in particular those that reach women and girls will be a key challenge over the next years. This survey solicited views on whether the mandate of the Global Fund should be expanded as well as how well Global Fund nancing has strengthened community level systems and capacities.

EXPANDING THE MANDATE OF THE GLOBAL FUND BEYOND HIV, TB AND MALARIA

Chart 8: If you think Global Fund should expand its mandate, what additional areas should it cover?
27%

20%

70% of respondents said that the Global Fund should expand its mandate beyond funding HIV, TB and malaria-speci c interventions, while 23% said it should not (7% don’t know) Of those 70% who recommended an expanded mandate, 27% recommended expanding the mandate to include sexual and reproductive health rights and primary health care respectively and 26% to include maternal, newborn and child health. Respondents could choose more than one option. Among the 20% who selected “other”, the analysis clearly highlighted health systems strengthening, including human resources, followed by recommendations to expand the mandate to include chronic diseases including cancer, non-communicable diseases, tobacco, education and nutrition.
Maternal, newborn and child health 26% Other 20%

27%

26%

Primary health care 27%

Sexual and Reproductive Health and Rights 27%

STRENGTHENING COMMUNITY SYSTEMS

Chart 9: Global Fund financing for Community Systems Strengthening has contributed to the strengthening of community level capacity and internal systems (n=899)
5% 11% 40% 16%

51% of respondents agreed or strongly agreed that Global Fund nancing for Community Systems Strengthening has contributed to the strengthening of community-level capacity and internal systems (including management, technical and nancial capacity), while 21% disagreed or strongly disagreed. 28% selected ‘neither’, which may re ect a lack of awareness of CSS, or its lack of explicit application in a large number of countries. Further analysis will be done of the breakdown of responses by country to help focus the further promotion of the CSS Framework which was developed in 2010.
Strongly agree 11% Agree 40% Neither 28% Disagree 16% Strongly disagree 5%

28%

22

DELIVERING ON A HUMAN RIGHTS APPROACH FOR THE THREE DISEASES: WHERE SHOULD THIS TAKE US?
The Global Fund has distinguished itself as a multilateral nancing mechanism that has made signi cant contributions to protecting, promoting and ful lling human rights through scaling up prevention, treatment, care, and support for HIV, tuberculosis and malaria. In this primary role of nancing and not implementing programs, the Global Fund has played a vital role both in supporting interventions to overcome stigma, discrimination and other human rights-related barriers to prevention, treatment, care, and support, as well as in using its unique position to promote positive legal and policy change. Particularly in regard to HIV, the Global Fund has stimulated the creation of in-country processes that have opened doors to participation in HIV programming for people living with and vulnerable to HIV, and the inclusion of the voices of people living with and vulnerable to HIV is required to be demonstrated in all HIV funding applications. However, concerns remain that the Global Fund may inadvertently fund interventions that may violate human rights of particularly vulnerable populations, or that opportunities to promote human rights more actively may be missed. The Global Fund is writing its new strategy for 2012 – 2016, and is seeking to identify strategic interventions that address human rights and access (to prevention, treatment, and care and support) as a more centralized pillar of its work. In addition to the challenges faced by most at risk populations in concentrated HIV epidemics – across the three diseases, there are also persons who are particularly underserved. The potential for human rights related barriers to accessing prevention, treatment and care and support services exists in such contexts also. It is also imperative that the Global Fund ensures that the programs it supports do not infringe upon human rights. The survey sought views on whether Global Fund nancing is doing enough to respect human rights and whether funding should be made available in middle-income countries with high disease prevalence among most-at-risk populations. It also sought views on how civil society’s ability to function as a watchdog has been strengthened or constrained as a result of engagement in the Global Fund.

HUMAN RIGHTS REFLECTED IN THE GRANTS FUNDED BY THE GLOBAL FUND 34% of respondents said that the Global Fund was doing enough to ensure human rights are adequately respected and addressed in the grants they fund. 30% of respondents said the Global Fund was not doing enough. 36% of respondents said they did not know.

36%

Chart 10: Human rights are adequately respected? (n=1037)
Don’t know 36% No 30% Yes 34%

34% 30%

23

65% of respondents said funding policies should allow funding to be available for proposals addressing situations of high disease prevalence among most-at-risk populations in Upper Middle Income countries, while 23% did not agree4.

12%

23%

Chart 11: Should Global Fund Funding policies allow funding to be available for proposals addressing situations of high disease prevalence among most-at-risk-populations in Upper Middle Income Countries? (n=1037)
Don’t know 12% No 23% Yes 65%

65%

27% of respondents reported that civil society’s ability to function effectively as a watchdog had been constrained by its direct engagement in the Global Fund. 23% said it had been strengthened while 25% said it had not been affected much. 25% said they did not know. This very mixed response re ects the diversity of circumstances in which civil society operates. There is considerable regional variation, with 17% of respondents from Eastern Europe and Central Asia, and as high as 36% of respondents from East Africa saying that civil society’s watchdog role had been constrained.
23%

27%

Chart 12: To what extent has civil society’s ability to function effectively as a watchdog been either constrained or strengthened through direct engagement in Global Fund structures and processes? (n=822)
Constrained 27% Don’t know 25% Not affected much 25% Strengthened 23%

25%

25%

4 Note that a new Global Fund policy on Eligibility Criteria, Counterpart Financing Requirements, and Prioritization of Proposals was approved by the Global Fund board after this survey was conducted. Under this policy, upper middle income countries with high or extreme disease burdens among de ned populations may, with certain conditions, apply for funding under either the “general” or “targeted” funding pools.

24

USING THE MONEY WISELY: FUNDING THE RIGHT THINGS
In order to maximize the impact of the Global Fund investments on the three diseases and save more lives, it will be more important than ever that the Global Fund “funds the right things.” This includes ensuring that funding reaches those who need it most, when they need it. The survey asked respondents for their views on a number of questions relating to how well funding is being appropriately targeted to those most-at-risk and also for opinions on the importance and effectiveness of how funding is sought and distributed among non-government actors and governments in countries.

ALLOCATING FINANCING TO THE THREE DISEASES When asked if nancial allocation was appropriately distributed according to the epidemiology of HIV, TB and malaria in country, 17% said the allocation was about right. Globally, views on which areas are being neglected were quite evenly divided across a number of possible options. Respondents could choose more than one option.
17%

Chart 13: Is financing from the Global Fund being allocated appropriately given the epidemiology of the three diseases in your country?
Yes, the allocation is about right. 17% No, HIV is being neglected. 9% No, HIV among key affected populations is being neglected. 11% No, TB is being neglected. 10% No, TB at the community level is being neglected. 11% No, Multiple Drug Resistant TB is being neglected. 11% No, Malaria prevention is being neglected. 9% No, Malaria diagnosis and treatment is being neglected. 9% Other 13%

13%

9%

9%

9%

11%

11% 11%

10%

There was also considerable variation in responses across regions. For East Africa and Indian Ocean and East Asia and the Paci c, over 25% of respondents said the allocation was about right. For Eastern Europe and Central Asia, less than 15% of respondents felt the allocation was about right, with all other categories indicated as “neglected” by at least 10% of respondents. For Latin America and the Caribbean, responses indicated resources are not being allocated appropriately across all categories, highlighting HIV, tuberculosis, malaria prevention, diagnosis and treatment as being neglected in particular, followed by HIV among HIV affected populations and tuberculosis at the community level. In South and West Asia, the majority of respondents said the allocation was about right, with some highlighting multiple-drug resistant tuberculosis (MDR-TB) and malaria diagnosis and treatment as being neglected. In Southern Africa, over 30% felt the allocation was about right, with some highlighting MDR-TB and malaria diagnosis and treatment as being neglected. Over 20% of West and Central Africa respondents indicated allocation about right, with some concern about tuberculosis at the community level being neglected. These ndings, only indicative, do show the importance of considering differences in regional and country contexts when making decisions on allocating funding, and also the importance of using epidemiological data to inform decision-making about funding priorities. That there are such divergent opinions on disease priorities within the same region suggests that factors other than epidemiology are informing people’s views.

25

MEETING THE NEEDS OF MOST AT RISK POPULATIONS Prevention Globally, from 35% to over 55% of respondents agreed that Global Fund nancing for HIV prevention programs is being targeted appropriately to the various most-at-risk populations in proportion to the epidemiology in their countries. Notable however, was that although there was a high proportion of “neither”, more than 40% of respondents from East Africa and the Indian Ocean, Eastern Europe and Central Asia, Southern Africa and West and Central Africa either disagreed or strongly disagreed that Global Fund nancing for HIV prevention programs is being targeted appropriately to men who have sex with men and transgender populations.

Chart 14: Proportionate to the epidemiology of HIV in your country, Global Fund financing for HIV prevention programs being targeted appropriately to the most at risk populations
Disagree, Strongly Disagree Vulnerable children and orphans Refugees and migrants Prisoners and detainees Male, female and transgender sex workers People who inject drugs Transgender persons Men who have sex with men Youth Women and girls
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60%

Neither

Agree, Strongly Agree

Care, support and treatment Responses to the question looking at whether Global Fund nancing for HIV care, support and treatment is being used effectively to deliver services to key affected populations yielded different results. For many key affected population groups, respondents agreed that nancing for HIV care, support and treatment services is being appropriately targeted. However, more than 30% disagreed that nancing is being effectively used to deliver services to refugees and migrants, prisoners and detainees, sex workers and their clients, people who inject drugs, transgender populations and men who have sex with men.

Chart 15: Is Global Fund financing for HIV care, support and treatment in your country being used effectively to deliver services to key affected populations?
Vulnerable children and orphans Refugees and migrants Prisoners and detainees Male, female and transgender sex workers and their clients People who inject drugs Transgender persons Men who have sex with men Youth Women and girls
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%

No Don’t know Yes

26

USING THE MONEY WISELY: STRENGTHENING GOVERNANCE AND OVERSIGHT TO GET IT RIGHT
The Global Fund was set up in 2001 to save lives. In the ten years since its creation, it has funded the detection and treatment of 7.7 million cases of tuberculosis, the distribution of 160 million long lasting insecticidal treated nets, and the maintenance of a growing number of people on antiretroviral therapy. Today, that gure is more than 3 million people. However, by the very nature of its mandate – to focus on countries most in need – the Global Fund works in countries and environments that present high levels of risk. This includes countries where programmatic and oversight capacities are weak, or where nancial controls are inadequate, or those commonly de ned as “fragile” states. From the beginning, the Global Fund has had an uncompromising attitude toward misuse of funds. It has multiple layers of programmatic and duciary controls that are used to rapidly identify and address risk situations identi ed by the Global Fund or its independent veri cation experts working at country level (called ‘Local Fund Agents’). Instances of suspected or con rmed fraud have received a swift and determined response from the Global Fund – with programs suspended or terminated in a number of countries, and concerted efforts to recover misspent funds. Where ndings of irregular expenditures at country level are found, the Global Fund transparently communicates these ndings to the world. Over the last two years, the Global Fund has been reinforcing its fraud detection and risk-management processes, with particular attention to the role of Local Fund Agents and fraud-prone activities at the country level. The survey sought views on strengthening existing nancial management systems and understanding where respondents would report suspicion of fraud. It also explored civil society’s representation on the countrycoordinating mechanisms as an indication of how well most at risk populations, i.e. those who need Global Fund nancing most, are engaged in governance at the country-level.

STRENGTHENING EXISTING FINANCIAL MANAGEMENT SYSTEMS TO INCREASE EFFECTIVENESS All options presented for strengthening existing nancial management systems to increase effectiveness received strong support from respondents. 55% of respondents said the Global Fund could be more effective at preventing fraud and nancial losses by engaging more closely with Country Coordinating Mechanisms to strengthen their grant/program oversight and 54% said it could be more effective by supporting an increased and more formal watchdog role for civil society. Respondents could choose more than one option.

Chart 16: Global Fund could be more effective at preventing fraud and financial losses by
Supporting increased and more formal watchdog role for civil society (n=1389) Don’t know No Yes

Supporting enhanced role for Parliamentarians in oversight and accountability (n=1643)

More frequent secretariat visits to countries (n=1392)

Investing more in the Local Fund Agents to permit closer monitoring (n=1386)

Funding stronger oversight roles for in-country partners (n=1398)

Establishing regional of ces (n=1397)

Engage more closely with CCMs to strengthen their grant/program oversight (n=1396)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

55%

27

The Global Fund’s Of ce of the Inspector General (OIG) has visited and reported on grant implementation in many countries, and provides very detailed information on how to report suspected cases of fraud on the Global Fund website. Nonetheless, only 10% of respondents said they would report suspected cases of fraud through the OIG. 18% did not know where they would make such a report. Since this is a relatively well-informed group of respondents, these results suggest that the Global Fund needs to do more to inform stakeholders about mechanisms for reporting suspected fraud.

Chart 17: If you suspected fraud or misappropriation of funds or medical supplies in your country, who would you report it to? (n=822)
Don’t know 18% CCM chair or vice-chair 11% Fund Portfolio Manager 11% Of ce of the Inspector General 10% Other 9% Local Fund Agent 9% Principal Recipient 8% My sector’s representative on the CCM 8% Media 5% Board member 5% Police 3% Technical Partners 2% Member of Parliament 1%

2% 1% 3% 5% 5% 11% 8% 18%

8%

11%

9% 9%

10%

CIVIL SOCIETY REPRESENTATION ON THE CCM 51% agreed that civil society representation on the CCM is aligned with the epidemic so that the mostaffected groups are represented on the CCM. 26% disagreed, while 18% selected ‘neither’. Looking further into the data at responses by sector (Chart 19) shows different perspectives on whether civil society representation on the CCM is aligned with the epidemic in the country. Over 60% of recipient country government, trade union, and developing country NGO respondents agreed that civil society representation is aligned with the epidemic, while less than 40% of faith-based organization, multilateral partner and Foundation respondents shared that view.

Chart 18: Civil society representation on the CCM is aligned with the epidemic in the country, so that the most-affected groups are represented on the CCM (n=846)
Strongly agree 15% Agree 36% Neither 18% Disagree 18% Strongly disagree 8% Not applicable 5%

5%
8%

15%

36%

18%

18%

28

Chart 19: Civil society representation on the CCM is aligned with the epidemic in the country, so that the most-affected groups are represented on the CCM: Breakdown by Sector
Agree, Strongly agree Neither Disagree, Strongly disagree Not applicable

Recipient Country Government PLWD Other Multilateral Partners Member of Parliament Global Fund Secretariat Foundation Faith-Based Organization Employee Association or Trade Union Donor Government (Bilateral Partner) Developing (Recipient) Country NGO Developing (Non-Recipient) Country NGO Developed Country / International NGO Community Based Organization Communities Business / Private Sector Academia
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

In most regions (Chart 20), the majority of respondents agreed or strongly agreed that civil society representation on the CCM is aligned with the epidemic in the country. The lowest level of agreement was from respondents in Eastern Europe and Central Asia, where less than 40% of respondents strongly agreed or agreed while 36% of respondents disagreed or strongly disagreed.

Chart 20: Civil society representation on the CCM is aligned with the epidemic in the country, so that the most-affected groups are represented on the CCM
Agree, Strongly agree
West and Central Africa Southern Africa South and West Asia Middle East and North Africa Latin America and Caribbean Europe and North America Eastern Europe and Central Asia East Asia and Paci c East Africa and Indian Ocean
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

Neither

Disagree, Strongly disagree

Not applicable

29

SUGGESTIONS ON STRENGTHENING CCM OPERATIONS AND OVERSIGHT A large number of comments were received from respondents making suggestions for how Country Coordinating Mechanisms could be strengthened based on their experiences. Comments were made in the areas of oversight, accountability, equality of voice, representation and communication mechanisms. The most frequently occurring comments related to accountability and representation, where respondents made detailed and practical suggestions for how this could be improved. A few key points made by respondents are listed below:

Distance CCM from government and political ties and focus on strengthening a balanced representation of the community possibly using Community Engagement Model (Communities being claim holders, government being duty-bearers, CSOs and NGOs being rights engagers) CCM should be convened by neutral stakeholders (regional, WHO, UNICEF) pro-actively seeking comprehensive stakeholder representation/membership, acting more as a Board in reviewing and overseeing progress and audits. Protocols should be strengthened to make the CCMs more of a civil society entity. Initiate small regional committees or structures to mediate and manage con ict of interest Strengthen technical working groups per disease within the CCM Consider two structures: one to oversee program processes and issues and the other to oversee funding processes and issues Enable communities to voice opinions with open communication channels CCMs need to improve technical capacity to effectively oversee Principal and Sub-Recipients Local or regional Global Fund of ces should oversee CCM performance and assist with problems Implementation should continue on country level but still needs the Global Fund to be a source of guidance for both operational and technical assistance and to provide supervisory mechanisms for CCMs Ensure greater representation from most-at-risk populations in the CCMs Improve communication and media coverage of the Global Fund at country level

30

IMPLEMENTING WITH INCREASED IMPACT
In the past nine years, the Global Fund has proven itself an ef cient and cost-effective mechanism for expanding the world’s response to the global pandemics of HIV, tuberculosis and malaria. At the same time, questions exist as to whether the Global Fund’s systems and processes for accessing funding are still as rapid and simple as originally planned. In turn, this raises for discussion the topic of whether there is suf cient predictability in Global Fund nancing to ensure continued scale-up of high quality services at the country level in a sustainable and cost-effective manner. In a global environment there is an increasing focus on ensuring improved value for money (cost effectiveness) and increased impact for the money spent (ensuring that resources are spent on the right interventions, in the right contexts, and for the right people). The survey sought to gain insights into how effective the country-level model of the Global Fund is, identify the potential weaknesses and solicit suggestions for other models that might be considered.

COUNTRY-LEVEL MODEL 70% of respondents said the Global Fund’s country-level model is working somewhat or very well. 26% responded that it was not working well and 6% said it was not working at all. 11% said they did not know. Chart 21 shows the responses on how well the various elements of the country-level model are working.

Chart 21: In your opinion, what is working well in the country-level model of the Global Fund?
Don’t know Not working at all Not working well Working somewhat well Working very well

Partners and Global Fund coordination Strengthening capacity in implementing countries Feedback from countries to the GF Public private partnership Alignment of GF with national strategies and policies Country ownership in priority-setting & implementation CS in uence & engagement in governance & oversight CCM partnership model
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

A number of questions addressed various aspects of the Global Fund’s current model and performance in terms of the engagement of non-government sectors, which is fundamental to the Global Fund’s principles and business model. Some of the ndings are highlighted below. The Global Fund’s ‘Dual Track Financing’ policy recommends that countries routinely include an implementer from both the government and non-government sectors in each disease proposal. The policy was described as a means to “further enable civil society and the private sector to play their critical roles.” Dual Track Financing would “increase absorptive capacity, accelerate implementation and performance of grants, and strengthen the weaker sectors.”

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5%

14%

52% of respondents agreed or strongly agreed that Dual Track Financing was achieving its objectives, while 20% disagreed or strongly disagreed. 28% selected ‘neither’.

38% 15%

Chart 22: Dual Track Financing achieved these objectives (n=899)
Strongly agree 14% Agree 38% Neither 28% Disagree 15% Strongly disagree 5%

28%

2% 1% 3% 6% 53%

88% of respondents agreed or strongly agreed that the Global Fund needs to sustain its commitment to engagement of non-government sectors at country level in all new funding channels and mechanisms (such as National Strategy Applications, Health Systems Joint Funding Platform, Single Stream of Funding).

Chart 23: The Global Fund needs to sustain its commitment to engagement of nongovernment sectors at country level in all new funding channels and mechanisms (n=899)
Strongly agree 53% Agree 35% Neither 6% Don’t know 3% Disagree 2% Strongly disagree 1%

35%

8%

67% of respondents agreed that it should be mandatory, not optional that funding go to both government and non-government Principal Recipients, while 25% did not.

25%

Chart 24: It should be mandatory, not optional, that funding go to both government and non-government Principal Recipients (n=899)
Don’t know 8% No 25% Yes 67%

67%

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The different opinions of the various sectors on this issue – NGOs, governments, private sector, academia, multilateral partners, donors and the Global Fund Secretariat – are very apparent. Global Fund Secretariat and recipient country government respondents did not agree it should be mandatory that funding go to both sectors (although in both cases, the number of respondents was small) while NGOs (recipient and nonrecipient countries) agree it should be mandatory. The majority of respondents across all regions felt that funding to both sectors should be mandatory. In Latin America and the Caribbean, support for this option was the lowest at 51%, while 38% felt funding to both sectors should remain optional (Chart 25). This is an interesting nding, given that this region has the highest proportion of non-government Principal Recipients.

Chart 25: It should be mandatory, not optional, that funding go to both government and non-government Principal Recipients: Breakdown by region
Yes No Don’t know

West and Central Africa Southern Africa South and West Asia Middle East and North Africa Latin America and Caribbean Europe and North America Eastern Europe and Central Asia East Asia and Paci c East Africa and Indian Ocean
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%

20%

Chart 26: Has Global Fund financing done enough to support increased service availability and impact at the community level? (n=899)
51%
Don’t know 20% No 51% Yes 29%

29%

51% of respondents said that Global Fund nancing had not done enough to support increased service availability and impact at the community level, while 29% said it had. 20% did not know.

The data show differences by regions (Chart 27) and also present a diversity of perceptions on the issue depending on which sector respondents come from. More than 60% of faithbased organizations, donor government, people living with or affected by the three disease, community-based organizations and Communities feel that the Global Fund has not done enough, while this gure is less than 40% for academia, Global Fund secretariat and recipient country government respondents.

Chart 27: Has Global Fund financing done enough to support increased service availability and impact at the community level? Breakdown by Region (n=899)
Don’t know No Yes

West and Central Africa Southern Africa South and West Asia Middle East and North Africa Latin America and Caribbean Europe and North America Eastern Europe and Central Asia East Asia and Paci c East Africa and Indian Ocean
0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65%

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IDEAS FOR INNOVATION AND IMPROVEMENT
Respondents were asked to suggest any innovations that could enable the Global Fund to have greater impact. Many comments were in the form of recommendations to improve the current model. Other comments suggested adopting more practices and models from the private sector to increase ef ciency and impact. These suggestions may be relevant to the Global Fund’s Comprehensive Program for Reform, which is currently developing several important changes to internal systems and policies, as well as to the Global Fund’s Strategic Framework. Some of the comments are included below:
‘Work nationally but enable locally’ with highly diversi ed and localized approaches where committees can be engaged and supported to remain local (not migrate to urban areas), run their own services supported by the government; train local community members and pay them as public health care workers. Establishment of regional Global Fund of ces that are staffed by personnel able and willing to make frequent visits to improve accountability, oversight, transparency, and monitoring and evaluation to assist country’s performance and fund utilization system. “Introduction of external monitoring system for programs within the same region. This [could] greatly improve collaboration between countries in the same region and at the same time increase exchange of ideas and promote integrity between neighboring countries.” Adopt a rights based approach to programming.

o “Invest in building the capacity and empowering
civil society, not only large international NGO’s but national and CBO’s to partner Global Fund programs that are implementing effectively and in an accountable and transparent manner.”

o Increase partnership and involvement of
stakeholders across the spectrum of populations to improve accountability, capacity building and transparency. Moving away from bureaucracy and government politics with less involvement of government and large NGOs. Increase private sector best practices in general administration and implementation of grants and increase funding to CSO rather than through government structures. Multi-sectoral approach, improving primary health and health system strengthening, taking on public private partnership models, building effective networks and providing sector-wide support to effectively ght against AIDS, TB and malaria. “Continue to promote integration of health programs directly related to AIDS, malaria, TB with other healthcare delivery, especially when those interventions require the same human resources and health systems” “Coordinate with and support technical agencies to improve national policies and practices and use the national operational and epidemiological information for action.” Simpli cation of process and orientation to the Global Fund by using the media and online resources, thereby increasing access of materials to populations in countries. Engage media and press to have greater visibility to the general public and disseminate Global Fund principles and practices, along with success stories to encourage adoption of best-used practices. “Introduce standard uniform reporting templates to all PRs, to save LFA time when carrying out reviews so that we are able to meet the very tight deadlines set by the Global Fund.”

o “I think as much emphasis should be put on
making sure that human rights are respected in Global Fund-funded programs as is put on fraud prevention. Similar structures should be set up to vet all proposals for minimum human rights protections, and governments should not be allowed to keep funds away from lesbian, gay, bi-sexual and transgender groups because programs are ‘country driven’, for instance. An important issue is the potential use of Global Fund funds to pay for forced sterilization procedures in women living with HIV. Procedures for informed consent should be universal and mandatory for receipt of funds.” Global Fund advocacy:

o Advocacy for reduced debt within countries to
strengthen multi-sectoral systems that effect Global Fund efforts

o Advocacy for lower costs for medical supplies
and drugs

o Enhanced support for CCMs to play more active
role in policy advocacy with the government of the country and the mobilization of state resources and private sector.

o Focus on low-income countries for funding, middle
income for advocacy programs. Expand the support to rural areas and create income generating micro-enterprises that serve to offer the same prevention opportunities and self-sustainability of the initiatives Increased surveys for feedback from the community and infected and affected populations.

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ANNEX 1: SURVEY QUESTIONNAIRE
YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA 1. INTRODUCTION
Thank you for taking the survey to ensure your voice is heard on the future direction and operations of the Global Fund. The following survey has been designed as part of the Global Fund’s biennial Partnership Forum consultations taking place between March and June 2011. Other opportunities include broad-based eForum discussions and a face-to-face meeting of partners. The survey has been structured around the following seven headings and should take approximately 20 minutes to complete. 1. 2. 3. 4. 5. 6. Introduction Respondent information Principles and mandate Implementation and results Constituency engagement and governance Oversight and accountability

7. Innovation for impact The objectives of the survey are to: - Understand the concerns and views of Global Fund constituencies, including those who are interested but have not yet been able to engage with the Global Fund. - Give diverse constituencies the opportunity to input into the ongoing evolution and work of the Global Fund - Provide an opportunity for partners to input into the 2011 Partnership Forum - Inform strategic discussions and direction of the Global Fund - Inform implementation of Global Fund grants and policies The survey is available in four languages (English, French, Spanish and Russian). If you wish to take the survey in a language other than English please visit the consultation website. All information gathered will be treated with the utmost con dentiality and you also have the option to complete the survey anonymously. Where you feel you wish to express opinions or views that may be too long for the survey format, we invite you to join the eForum discussion by sending an email to: join-globalfundconsult@eforums.healthdev.org For more information about this project please click here or see the Global Fund website

2. RESPONDENT INFORMATION
Please tell us about yourself. 1. If you would like to receive a copy of the survey report please provide your contact details. This will not be used for any other purpose. Name ______________ Email ______________ 2. What is your sex? Transgender, Male or Female *3. Age 21 and under, 22-34, 35-44, 45-54, 55-64 or 65+ *4. Which region do you live in? - Latin America & Caribbean - West & Central Africa - Middle East & North Africa 5. Which country are you living in? - South & West Asia - Southern Africa - Eastern Europe & Central Asia (Country List Drop Down Menu)
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- East Asia & Paci c - East Africa & Indian Ocean - Europe & North America

YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
6. What sector are you in? (please choose which one best represents you) Academia Communities (NGOs representative of the Communities Living with the Diseases) Person living with or affected by HIV, TB or malaria. Developed Country / International NGO Developing (Recipient) Country NGO Developing (Non-Recipient) Country NGO Faith-Based Organization Community Based Organization Donor Government (Bilateral Partner) Foundation Multilateral Partners (eg. UNAIDS, WHO, Stop TB, Roll Back Malaria) Business/PrivateSector Employee Association or Trade Union Recipient Country Government Member of Parliament / Working with Members of Parliament Global Fund Secretariat Other (please specify) __________________ 7. In addition to the sector selected above, indicate if you also are a member of or represent one of the following population groups: Women and girls Youth Youth / Most at risk population Men who have sex with men Transgender persons People who inject drugs Male, female and transgender sex workers Prisoners Refugees and migrants People living with HIV Vulnerable children and orphans Other (please specify)_________________ 8. If you represent an organization, how is your organization engaged with the Global Fund processes? CCM Member Board or Committee Member/Alternate Principal Recipient Sub-Recipient Sub-Sub Recipient Technical Assistance provider Advocate Not directly engaged Other (please specify) ________________

3. PRINCIPLES AND MANDATE
The Global Fund is a unique global public/private partnership dedicated to attracting and disbursing additional resources to prevent and treat HIV, tuberculosis and malaria. This partnership between governments, civil society, the private sector and affected communities represents a new approach to international health nancing. The Global Fund works in close collaboration with other bilateral and multilateral organizations to supplement existing efforts dealing with the three diseases. Since its creation in 2002, the Global Fund has become the dominant nancier of programs to ght HIV, tuberculosis and malaria, with approved funding of US$ 21.7 billion for more than 600 programs in 150 countries. The Global Fund’s principles and mandate are described in the Framework Document of the Global Fund to Fight AIDS, TB and Malaria, which you can nd here. *9. The Global Fund continues to respect and operate according to the principles outlined in its Framework Document. (for each variable respondents selected from Strongly agree, Agree, Neither, Disagree, Strongly disagree) i. Operate as a nancial instrument, not an implementing entity ii. Make available and leverage additional nancial resources iii. Support programs that re ect national ownership & respect country-led formulation & implementation iv. Operate in a balanced manner in terms of different regions, diseases & interventions v. Pursue an integrated, balanced approach to prevention, treatment and care vii. Support programs that re ect national ownership & respect country-led formulation & implementation viii. Establish a simpli ed, rapid and innovative grant-making process and operate transparently, with accountability. The fund should make use of existing international mechanisms and health plans ix. Focus on performance by linking resources to the achievement of clear, measurable and sustainable results
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YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
*10. Ten years after its founding, do you think all of the Global Fund’s principles listed above are still relevant? - Yes or No *11. Do you feel any key principles of relevance to the Global Fund are missing from the framework document? - Yes or No 12. If you think any are missing or no longer relevant, please explain: __________________________________________ *13. Is the Global Fund doing enough to ensure that human rights are adequately respected and addressed in the grants we fund? -Yes, No or Don’t know
The World Bank classi es countries according to income level, as Low Income, Lower Middle Income and Upper Middle Income.

*15. Ten years after its establishment, the Global Fund now needs to (please tick one or more): Continue to focus rst on increasing the numbers of lives saved Increase attention to ensuring the quality of interventions that are funded Increase attention to epidemiology to ensure that the only proposals that are funded are those that re ect a “know your epidemic” analysis and address the most affected populations in a country Increase attention to human rights even if it means reaching lower total numbers of people *16. In order to have greater impact, should the Global Fund expand its mandate beyond funding HIV, TB and malaria speci c interventions? -Yes, No or Don’t know 17. If you think Global Fund should expand its mandate, what additional areas should it cover? Primary health care Sexual and Reproductive Health and Rights Maternal, newborn and child health Other (please specify) _________________

*14. Should Global Fund funding policies allow funding to be available for proposals addressing situations of high disease prevalence among most-at-risk-populations in Upper Middle Income Countries? -Yes, No or Don’t know

4. IMPLEMENTATION AND RESULTS
As of the end of 2010, Global Fund has supported 3 million people on ARV treatment, distributed 160 million insecticide treated bed-nets, and treated 7.7 million Tuberculosis patients with DOTS. Scaling up and sustaining these results requires that effective systems of implementation be in place at all levels, and that limited resources be allocated to evidence-based, high impact interventions. Investing for Results 18. Proportionate to the epidemiology of HIV in your country, Global Fund nancing for HIV prevention programs is being targeted appropriately to the most at risk populations. (for each variable respondents selected from Strongly agree, Agree, Neither, Disagree, Strongly disagree) i. ii. iii. iv. v. vi. Women and girls Youth Men who have sex with men Transgender persons People who inject drugs Male, female, and transgender sex workers and their clients vii. Prisoners and detainees viii. Refugees and migrants ix. Vulnerable children and orphans 19. Is Global Fund nancing for HIV care, support and treatment in your country being used effectively to deliver services to key affected populations? (for each variable respondents selected from Yes, No, Don’t know) i. Women and girls ii. Youth iii. Men who have sex with men iv. Transgender persons v. People who inject drugs vi. Male, female, and transgender sex workers and their clients vii. Prisoners and detainees viii. Refugees and migrants ix. Vulnerable children and orphans

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YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
*20. Is nancing from the Global Fund being allocated appropriately given the epidemiology of the three diseases in your country? - Yes, the allocation is about right. - No, HIV among key affected populations is being neglected. - No, TB at the community level is being neglected - No, Multiple Drug Resistant TB is being neglected. - Other(please specify) _______________________ - No, HIV is being neglected. - No, TB is being neglected. - No, Malaria prevention is being neglected. - No, Malaria diagnosis and treatment is being neglected

Non-Government Implementers and Community Systems Strengthening The Global Fund’s Dual Track Financing policy recommends that countries routinely include an implementer (Principal Recipient or PR) from both the government and non-government sectors (including the private sector, civil society, and faith based organizations) in each disease proposal. The policy was described as a means to “further enable civil society and the private sector to play their critical roles.” According to the board decision, Dual Track Financing would “increase absorptive capacity, accelerate implementation and performance of grants, and strengthen the weaker sectors.” For more information on dual track nancing see here. *21. Dual Track Financing achieved these objectives - Strongly Agree, Agree, Neither, Disagree, or Strongly disagree *22. It should be mandatory, not optional, that funding go to both government and nongovernment Principal Recipients - Yes, No or Don’t know *23. A minimum guaranteed percentage of funding should be negotiated in each grant to be implemented by non-government organizations - Yes, No or Don’t know

In 2007, the Global Fund board called for routine inclusion in proposals of measures to strengthen community systems in order to improve access to health service delivery and to achieve improved outcomes for HIV, TB and malaria programs. In 2010, the Global Fund developed the Community Systems Strengthening Framework, in order to help countries structure their funding requests for community organizations and activities. For a summary of the CSS framework see here. *24. Has Global Fund nancing done enough to support increased service availability and impact at the community level? - Yes, No or Don’t know * 25. Global Fund nancing for Community Systems Strengthening has contributed to the strengthening of community level capacity and internal systems (including management, technical and nancial capacity). - Strongly Agree, Agree, Neither, Disagree, or Strongly disagree

Country Coordinating Mechanisms Country Coordinating Mechanisms (CCMs) are central to the Global Fund’s commitment to local ownership and participatory decision-making. These country-level multi-stakeholder partnerships develop and submit grant proposals to the Global Fund based on priority needs at the national level. After grant approval, they oversee progress during implementation. CCM Core Functions
- Coordinate the development and submission of national proposals - Nominate the Principal Recipient - Oversee implementation of the approved grant and submit requests for continued funding - Approve any reprogramming and submit requests for continued funding - Ensure linkages and consistency between Global Fund grants and other national health and development programs

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YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA
*26. The Global Fund’s Country Coordinating Mechanism is a good and successful model for inclusive, transparent and effective program design, grant oversight and national accountability. - Strongly Agree, Agree, Neither, Disagree, Strongly disagree or Don’t know 27. If you strongly disagree, please indicate areas of weakness (you may choose more than one). - Does not perform grant oversight well - Does not manage con icts of interest well - Constituencies do not have an equal voice - Does not coordinate with other national programs - CCM members are not accountable to their constituencies - Other (please specify) _______________ 28. Can you suggest an alternative model that works or could work in your country? _______________________________________________________ *29. The Global Fund needs to sustain its commitment to engagement of non- government sectors at country level in all new funding channels and mechanisms (such as National Strategy Applications, Health Systems Joint Funding Platform, Single Stream of Funding) - Strongly Agree, Agree, Neither, Disagree, Strongly disagree, or Don’t know

5. CONSTITUENCY ENGAGEMENT AND GOVERNANCE
*30. In your opinion, what is working well in the country-level model of the Global Fund? (for each variable respondents selected from Working very well, Working somewhat well, Not working well, Not working well at all, Don’t know) i. Country Coordinating Mechanism (CCM) partnership model ii. Civil society in uence and engagement in governance and oversight iii. Country ownership in priority-setting and implementation iv. Alignment of the Global Fund with national strategies and policies v. Public private partnership vi. Feedback from countries to the Global Fund vii. Strengthening capacity in implementing countries viii. Partners and Global Fund coordination, drawing on each other to make the money work *31. Civil society representation on the CCM is aligned with the epidemic in the country, so that the most-affected groups are represented on the CCM. - Strongly Agree, Agree, Neither, Disagree, or Strongly disagree or Not applicable *32. The CCM in my country is doing enough to engage my constituency in: (for each variable respondents selected from Strongly agree, Agree, Neither, Disagree, Strongly disagree, Not applicable) i. Governance – in uence on CCM key functions of proposal development, PR selection and oversight ii. Watchdog / external oversight – monitoring performance and advocating for change iii. Implementation – Management of grants at country-level as PR iv. Implementation – Delivering services as SR or SSR v. Technical support for proposal development vi. Technical support for grant implementation vii. Policy development, including human rights issues *33. The Global Fund is doing enough to engage my constituency in governance through representation on the Global Fund board. - Strongly Agree, Agree, Neither, Disagree, or Strongly or Not applicable *34. Are there other models of private sector engagement the Global Fund is not pursuing and should? -Yes, No, Don’t know, or Other (please specify) _________________________________________ *35. In order to improve accountability and coordination and to better align with national nancing priorities, Ministry of Finance representation on CCMs should be a requirement. -Yes, No, Don’t know

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YOUR VIEWS ON THE GLOBAL FUND TO FIGHT AIDS, TUBERCULOSIS AND MALARIA 6. OVERSIGHT AND ACCOUNTABILITY
The Global Fund model includes a number of structures and systems to monitor grant performance and prevent fraud. These include the veri cation of all disbursement requests and results reports by a Local Fund Agent (an independent commercial auditing company contracted in each country for this purpose by the Global Fund), and the establishment of the Of ce of the Inspector General (OIG) which reports directly to the Global Fund board. External partners also play an essential role as observers and watchdogs. *36. The Local Fund Agent model is providing effective in-country oversight of: (for each variable respondents selected from Yes, No, Don’t know) i. Budgeting and nancial management ii. Monitoring and evaluation iii. Procurement and supply chain management *37. In addition to the strengthened nancial management systems already in place, the Global Fund could be more effective at preventing fraud and nancial losses by: (for each variable respondents selected from Yes, No, Don’t know) i. Engage more closely with CCMs to strengthen their grant/program oversight ii. Establishing regional of ces iii. Funding stronger oversight roles for in-country partners (such as development banks or technical partners) iv. Investing more in the Local Fund Agents to permit closer monitoring v. More frequent secretariat visits to countries vi. Supporting enhanced role for Parliamentarians in oversight and accountability vii. Supporting increased and more formal watchdog role for civil society viii. Other (please specify) ______________________________________________________ *38. If you suspected fraud or misappropriation of funds or medical supplies in your country, who would you report it to? (please choose one) - Board member - Fund Portfolio Manager - Police - CCM chair or vice-chair - Local Fund Agent - Member of Parliament - Don’t know - Media - My sector’s representative on the CCM - Technical Partners *40. How well do you feel you understand the processes of the Global Fund? - Extremely well, Very well, Moderately well, A little, Not at all

- Of ce of the Inspector General - Principle Recipient - Other (please specify) ____________________________ *39. To what extent has civil society’s ability to function effectively as a watchdog been either constrained or strengthened through direct engagement in Global Fund structures and processes? - Constrained, Strengthened, Not affected much, Don’t know

7. INNOVATION FOR IMPACT
41. If you had one innovative suggestion that you think would enable the Global Fund to achieve greater impact, what would it be? _______________________________________________________________________________________________ Thank you for taking the survey. We really appreciate your time. If you requested a copy of the report at the start of the survey, we will send it to you. Otherwise please check the consultation website for updates.

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ACKNOWLEDGEMENTS
This report was compiled with the help of many people working hard to encourage widespread participation in the e-Forum and the survey and to analyze the responses. The project was managed by Nadine Ferris France in her role as an Independent Consultant and implemented together with the AIDS Portal led by Robert Worthington www.aidsportal.org and CNS News led by Bobby Ramakant http://www.citizen-news.org/ on behalf of the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). We would especially like to thank the excellent e-Forum team, Bobby Ramakant, Evgenia Maron, Javier Hourcade Bellocq, Cecilia Dávila and Nyiama Tiburce as well as Meghan O’Reilly for her support. The Global Fund would like to extend thanks to Ioannis (Yani) Micropoulos at the Secretariat for his support to the team preparing this report. We would also like to acknowledge the following organizations that supported this project by ensuring widespread distribution through their networks, much needed to make this project a success: The International Council of Nurses (ICN), Microbicides Society of India, International Harm Reduction Association, Middle East and North African Harm Reduction (MENAHRA), Stop TB Partnership, Women’s Global Network for Reproductive Rights, Project Concern International India, Malaria Vaccine Initiative, CARAM Asia, PCI, PATH, The International HIV/AIDS Alliance and The Global Forum on MSM & HIV (MSMGF) Lastly, we would like to thank all those who took the time to complete the survey and participate in the e-Forum discussions, to make sure your voices could be heard.
Photo credits (in order of appearance in this report) Djibouti: The Global Fund / Didier Ruef (cover) Thailand: The Global Fund/John Rae Russia: The Global Fund/Oliver O’Hanlon Thailand: The Global Fund/John Rae Nicaragua: The Global Fund /John Rae Gambia: The Global Fund/John Rae

Consultations conducted on behalf of the Global Fund by:

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