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The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique

The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique Background: The Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique. Methods: We conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing. Results: Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In- country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in- country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement. Conclusions: To date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination. Resumo O Fundo Global é uma das ONGs mais importantes do mundo quando se trata do desenvolvimento da saúde global. Em 2015 foi desembolsado quase dez por cento de todo o orçamento à assistência no mundo direcionada à saúde. Em 2011, iniciaram um processo de reforma em resposta a alegações do mau uso das doações recebidas. As reformas têm focado no processo de aplicação do dinheiro, já as estruturas da ONG e seu paradigma tem permanecido intactos. Esta análise trata os resultados das discussões sobre o Fundo Global, seu paradigma de supervisão e monitoramento, e (Continued on next page) * Correspondence: ashley.warren@swisstph.ch Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland University of Basel, Petersplatz 1, 4003 Basel, Switzerland Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Warren et al. Globalization and Health (2017) 13:89 Page 2 of 14 (Continued from previous page) os resultados derivados em Moçambique. Pesquisadores realizaram 37 entrevistas em pessoa e uma entrevista por telefone com 38 partes interessadas em Maputo, Moçambique e membros do Conselho e Secretariado do Fundo Global na Suíça. Os entervistados em Moçambique eram representantes das estruturas locais do Fundo Global (p. ex. destinatários principais), do Ministério da Saúde, e ‘agencias bilaterais ou multilaterais e adidos da saúde ou desenvolvimento de embaixadas parceiras em Moçambique. Foram também incluídos representantes das Nações Unidas, consultores, e coordenadores das ONGs. Codificação temática revelou preocupações quanto à combinação da supervisão fraca no país com os requisitos rigorosos de monitoramento e avaliação; processos que estão conectados ao financiamento baseado em desempenho. A análise revelou que, apesar das mudanças associadas ao New Funding Model (Novo Modelo de Financiamento), a maioria dos consultados, tanto em Genebra como em Maputo, reconhecem que aínda existem desafios na estrutura e no paradigma do Fundo Global. A falta de um escritório em Moçambique tem alguns efeitos negativos, causando dependência em parceiros nacionais e também ineficácia na coordenação. Devido à fraca capacidade de absorção e de gerenciamento no pais, é necessária mais supervisão da que é possível atualmente nas visitas do gerente de carteira em Genebra. Os parceiros em Moçambique fornecem apoio aos beneficiários do Fundo, mas as diferentes tarefas, responsabilidades e prestações de contas precisam ser definidas mais claramente para conseguir uma parceria bem-sucedida a longo prazo. Além disso, os tomadores de decisão em Genebra reconhecem que a coordenação local é imperativa para uma implementação bem-sucedida; os parceiros continuam a apreciar o aumento do envolvimento do Fundo em Moçambique. Atualmente, não existem requisitos institucionais para uma coordenação formal, e o Fundo não tem uma presença continua dentro de grupos de coordenação em Moçambique. O Fundo Global precisa moldar a implementação de projetos e procedimentos de monitoramento às realidades locais que seriam destacadas através de uma coordenação formalizada. Keywords: Global Fund, Mozambique, Financial management, Performance-based finance, Coordination, Country oversight, Reform, New funding model representatives from both donor and recipient countries, Background The Global Fund to Fight AIDS, Tuberculosis, and non-governmental organizations (NGOs), the private Malaria (Global Fund) is a financial instrument estab- sector, and affected communities [8]. The Office of the lished in early 2002 [1]. Its formation was part of the Inspector General (OIG) is an independent body that “emergency response to accelerate the scale-up of con- oversees investment effectiveness including risks associ- trol of the major communicable diseases, especially ated with misused funds. The Technical Review Panel HIV/AIDS” in light of the Millennium Development (TRP) is an independent team of health and develop- Goals (MDGs) [2]. Governments provide approximately ment experts that evaluates proposals submitted to the 95% of Global Fund support; the private sector provides Global Fund [9]. the rest [3]. Since its inception, it has disbursed more The Principle Recipient (PR) is responsible for grant than US$30.6 billion [4]. In 2015, the Global Fund was implementation and can either be part of the public the world’s largest channel of finance for malaria and tu- sector, e.g.aministry,anNGO,or evenaprivate berculosis (40% and 49% of total support, respectively), company. The PR is under the direct supervision of and the second largest channel for HIV/AIDS (16% of the Country Coordinating Mechanism (CCM). The total support). In terms of overall contribution, the Glo- CCM is reflective of the Global Fund’s dedication to bal Fund was responsible for 9 % of funding for global local ownership and decision-making. It writes the health in 2015; it reached its maximum in 2012 and original grant proposal, nominates implementers, and 2013 when it oversaw the disbursement of 12% of the governs grant implementation. The CCM is a partner- total funds dedicated to development assistance for ship of country stakeholders including the private sec- health [5, 6]. tor, academic institutions, multilateral and bilateral The Global Fund has seven core structures, the: Board, development partners, civil society, and key affected Office of the Inspector General, Technical Review Panel, populations [9]. Principle Recipient, Country Coordinating Mechanism, The Global Fund Secretariat is responsible for the Staff / Secretariat, and Local Fund Agent [7]. The Global daily operations, primarily grant management. The Fund Board is the overall governing body responsible for Secretariat engages with Principal Recipients through defining policies, objectives, and strategies. It includes country teams. The Global Fund does not have offices in Warren et al. Globalization and Health (2017) 13:89 Page 3 of 14 recipient countries. Instead it uses Local Fund Agents are determined by countries’ burden of disease and (LFAs) to oversee grant management [9]. ability to finance. This approach is meant to enhance In October 2010 the Global Fund received its largest predictability of funding [25]. replenishment, to date, at US$11.7 billion despite allega- CCMs seek technical assistance to write grants for the tions of illicit use of funds in Zambia, the Philippines, three diseases (and health systems strengthening (HSS) and Mauritania and subsequent freezing of their cash which can either stand alone or be incorporated into a disbursements [10–13]. At the 22nd Board Meeting, the disease-oriented grant). Upon submission, grants are OIG released its Progress Report for March through screened for eligibility by the Secretariat and then passed October 2010. It outlined its findings from investigations along to the TRP which recommends technically sound of allegations of fraud, corruption, and misuse of funds proposals for funding. The Board gives official approval in seven countries [14]. On 23 January 2011, the Associ- of chosen grants. The grants undergo classifications and ated Press published a story, “Fraud Plagues Global budget cuts by the Board before being returned to the Health Fund” [15]. More than 250 media outlets world- TRP for negotiations, further reductions of the budgets wide covered the story and within days Germany froze through efficiency gains, and division between multiple its contribution to the Global Fund [16]. Over the com- PRs (and the subsequent necessary modifications to the ing months the Global Fund underwent independent budget). Then PRs and the Global Fund sign the final review, re-visited its 5-year strategy, and committed to grant agreement The most notable change in the NFM urgent reform [17–19]. Within one year, its Executive is that from the beginning, country teams are engaged in Director, Michel Kazatchkine, announced that he would country-level dialog on concept note development step down, cutting his tenure two years short [17, 20]. (Fig. 1). Gabriel Jaramillo, former Chairman and Chief Executive Officer of Sovereign Bank, was appointed as General Manager to oversee the transformation plan [21]. Mr. The Global Fund in Mozambique Jaramillo lacked technical expertise in health develop- As of 2016, Mozambique has been awarded 17 grants. ment, but he specialized in managing change in complex The Global Fund signed, committed, and disbursed a financial institutions during his 36 years of experience in total of more than US$972 million, US$802 million, and banking in Latin and South America and the US [22]. US$620 million, respectively, to Mozambique in its fight The OIG systematically audited recipients and identi- against the three diseases. (Please note that the discrep- fied US$118 million in losses as of 19 September 2013 ancy between values of signed, committed, and [23]. It is important to note that these losses are only disbursed is due to active grants.) The average portfolio 0.5% of the US$22.7 billion that the Global Fund had is US$466 million making Mozambique the 12th highest disbursed worldwide at the time [24]. Overall, the Global recipient of Global Fund support [3]. Fund has a particularly high level of financial account- Of Mozambique’s 17 grants, 12 have been awarded to ability, compared with other global health agencies, and the Ministry of Health, representing 86% of funds is diligent in its response to these relatively small abuses. disbursed to Mozambique. From 2004 and 2008 the Global Fund disbursed US$135.8 m into a health finan- cing basket, known as PROSAUDE [27]. PROSAUDE The new funding model was part of the state budget and was the common fund Reforms resulted in what became known as the New for development assistance in health (the basket fund) of Funding Model (NFM). It has five key characteristics: the Mozambique sector-wide approach to health sector flexible timeline, simplified grant application processes, funding. shorter approval processes, enhanced engagement of all In early grants, scorecards issued at the end of Phase I partners prior to grant submission, and improved pre- often reported “weak financial management practices dictability of funding [25]. In short, the reform focuses and capabilities within the MOH resulting in weak fi- on processes, not structure or paradigm. nancial accountability for resources used” along with dif- Initially the Global Fund application process was in ficulties tracking funds in PROSAUDE [28–32]. In 2011, distinct rounds announced by a call for proposals ap- in response to calls for increased accountability, the OIG proximately three months before a submission deadline. began an audit of Global Fund grants to Mozambique’s In the NFM, funding cycles are flexible and countries Ministry of Health for years 2008, 2009, and 2010 [27]. can submit a so-called concept note any time during Five months into the audit they concluded a total of windows. This allows countries to align the grant US$3,318,395 was inadequately accounted for. The timeline with national fiscal years and strategies. OIG recommended that the Ministry of Health repay Countries are eligible to apply for a pre-assigned the PROSAUDE. Overall, they concluded that there amount per disease, called “the envelope”. Envelopes were not “adequate controls … in place to manage Warren et al. Globalization and Health (2017) 13:89 Page 4 of 14 Fig. 1 Comparison of the Rounds-based funding process and the New Funding Model [26] the key risks impacting the Global Fund supported and the NGO coordinating body (Table 1). Interviews programs” [27]. were held in the offices of key informants in Switzerland This study was conducted to understand how the and Maputo, Mozambique. Interviews lasted approxi- Global Fund was experienced by key stakeholders in mately one hour but ranged from 45 min to three hours. Maputo, Mozambique and how recent reforms were ex- Investigators contacted prospective interviewees via perienced by key stakeholders in Mozambique as well as email. We obtained email addresses through professional by Global Fund stakeholders in Geneva, Switzerland. In late 2013 members of the research team conducted in- Table 1 Interviewees by representation terviews with 38 representatives from these two groups. Representation Number of Nomenclature in interviewees paper Global Fund Board 5 GFBoard Methods Global Fund Secretariat 5 GFSecretariat Primary data collection a b Global Fund Country Structure 4 GFCountryStructure Data was collected as part of a larger study on the influ- Academia 1 Academia ence of emerging donors in health development [33]. For the purpose of the larger study “emerging donors” Consultant Firm 2 Consultant includes public-private partnerships, philanthropic foun- b Non-governmental organization 3 NGO dations, corporate social responsibility programmes, Multilateral Agency 6 Multilateral Brazil, Russia, India, China, South Africa (the BRICS) OECD Partner 10 OECDPartner [34], and other emerging economies. The investigators Coordination Body 2 Coordination conducted 37 face-to-face and one phone-based semi- Total 38 structured in-depth interviews with stakeholders in Maputo, Mozambique and members of the Global Fund Location of interviews: 11 of the GF and 4 of the OECD and Multilateral Agency interviews were conducted in Geneva. The remaining 23 interviews Board and Secretariat in Switzerland. In-country stake- were conducted in Mozambique holders were representatives from Global Fund country includes Local Fund Agents, Country Coordinating Mechanism, Principal Recipients, and Sub-Recipients; members of the CCM may be a representative structures (e.g. Principle Recipient), the Ministry of of a multilateral agency or OECD Partner (Organization for Economic Cooperation Health, health or development attachés of partner em- and Development) bassies in-country, selected UN agencies, consultants, refers to interviewees in chronological order Warren et al. Globalization and Health (2017) 13:89 Page 5 of 14 contacts and official websites. Emails contained a brief engagement. The interview notes were indexed using the description of the research team, overall research framework and included sub-themes as determined by questions and objectives, and methods. Respondents the initial analytic coding [35]. suggested additional interviewee(s) who were then con- To maintain respondents’ anonymity, each interviewee tacted directly by the research team. was given a label with the following nomenclature: two Interviewers used a semi-structured interview guide letter country code, professional affiliation, and number (Additional file 1). Discussions included questions about (based on chronological order of interviews of people interviewees’ perspectives on overall changes in develop- with same professional affiliation). For example, “OECD- ment assistance for health and resulting influences at Partner2” for the second OECD Partner interviewed. country-level. Interviewees were also asked to share their opinions about who they perceived to be the most influ- ential private sources of finance including the Global Results Fund. Many of interviewers’ questions were in the Each country in the larger four-country study on emer- context of the Global Fund as an international non- ging donors for health had a different experience and governmental organization as opposed to an intergov- relationship with the Global Fund, but the general tone ernmental organization or a purely bilateral donor. We of response in Mozambique was that of a question- does asked open-ended questions about Global Fund engage- the current approach of the Global Fund fit with ment with the government and other donors. Inter- country-level needs? Most interviewees were active be- viewers allowed respondents to lead discussion for the fore, during, and after a protracted audit and were left most part and followed up with more detailed questions with concerns about the future of the Global Fund in for clarification. Interviewers also asked questions based Mozambique as it undergoes its first phase of reform. on insights provided in earlier interviews. Global Fund wants to follow only its own rules, and here The 15 interviews conducted in Switzerland followed a it is not working (Multilateral3). Perhaps the Global similar structure to those in Mozambique. Five of these Fund’s inflexibility to recipient needs is because it tends interviews were conducted much later, in mid-2015, to be obsessed with financial technicalities (Multilat- after an initial content analysis, and focused on the eral2). Respondents in both Mozambique and Global Fund and the New Funding Model, specifically Switzerland voiced concerns about the combination of (Academic1, NGO1, GFCountryStructure1, GFBoard4 weak country presence/oversight/guidance with strin- and 5, and GFSecretariat5). gent and cumbersome requirements for monitoring and In Mozambique 23 interviews were conducted. The evaluation (M&E) linked to performance-based financing discussions were primarily in English with periodic (Table 2). They felt this combination forces buttressing clarifications in Portuguese as one investigator speaks by partners. Respondents in Geneva also expressed con- Portuguese fluently. In Switzerland, 11 interviews were cern that perceived weaknesses of partners add risk in conducted with 13 interviewees. All discussions were in this paradigm. English. One phone-based interview was conducted in There appears to be a strong association in the minds English, and a second member of the in-country NGO of respondents in Mozambique between performance- coordination body provided input via email in response based funding, financial tracking, and the audit. This to later follow-up. results in concerns about the Global Fund’s overall Key informants in Mozambique received follow-up approach. There have been a lot of discussions about questions nine months after the initial interview. Of the Global Fund’s inflexibility and unrealistic demands of a 24 interviewees, eleven responded and two referred the developing country. ‘You are asking for oranges, but we investigators to new respondents who provided insights. only have bananas’ (OECDPartner1). Some respondents were more hopeful that distance from the audit will Analysis change the relationship with the Global Fund. The Glo- The corresponding author combined interviewers’ notes bal Fund has a horrendous story with performance-based into one Microsoft Word document per interviewee and financing. There have been improvements in the past two organized the material into fundamental themes- type of years (OECDPartner2). Both of these quotes illustrate a donor, aid management, health system, country context, disconnect between the perception of Performance- etc. The corresponding author uploaded interview notes based finance (PBF) at headquarter-level and at the into MAXQDA 11 (UdoKuckartz; Berlin, Germany) and country-level. In Geneva they believe this approach will read each at least three times. Each successive reading ultimately help countries identify obstacles to meeting was accompanied by descriptive, analytic, and thematic national goals and incentivize problem-solving. In coding, respectively, to assemble discussion points on Mozambique this approach feels based on implausible the Global Fund paradigm and country-level expectations and a resulting frustration. Warren et al. Globalization and Health (2017) 13:89 Page 6 of 14 Table 2 Summary of country-level perceptions of the Global Fund’s paradigm Aspect of paradigm Perceived country-level result Respondent(s) Performance-based financing � Recipients’ focus on disbursement rather than results OECDPartner10 � Burdensome administrative requirements GFCountryStructure4 � Duplication of reporting efforts from the Multilateral3 ground all the way to central level Emphasis on financial technicalities � Staff with financial rather than development GFBoard4 background who lack country experience Lack of country office � Other partners doing monitoring for the Global Fund OECDPartner2 � Global Fund is not engaged in country-level coordination Coordination1, OECDPartner3 � Forces partners to coordinate among themselves more Multilateral2 � Frequent deadlines and time stress GFSecretariat5 � Over-worked staff, communication challenges, out-of-touch GFSecretariat5 with realities on the ground � Dependent on expertise and interest GFBoard4, GFCountryStructure1, GF of single person (Fund Portfolio Manager) Secretariat5 Partnerships � Reliance on external consultants to develop proposals Multilateral2 � Early identification of gaps and provision of additional OECDPartner6 support � Undefined roles and concerns about accountability GFBoard2, GFCountryStructure4 � Potential for agenda alignment with single GFBoard1, GFCountryStructure2, GFSecretariat5, partner and less coordinated/multilateral approach OECDPartners2, 3, and 10 Interviewees in Mozambique and Geneva agreed there The technical support provided by partners is an inte- are problems associated with the current paradigm of gral component of the principle recipients’ success and, country oversight. The Global Fund has weak country therefore, the Global Fund’s success. The amount of sup- presence. Much more oversight is required; they must do port buttressing the Global Fund’s activities depends on more than disburse funds (OECDPartner10). Something the country (GFCountryStructure1). In Mozambique, that is missing in the Global Fund’s current approach is [w]e still have to rely on external consultants to develop close contact with the realities on the ground. There is our proposals (Multilateral2). Discussions in Geneva re- also a high level of internal movement that affects con- vealed that there is tension among stakeholders regard- tinuity (GFBoard4). GFBoard4 commented, [e]mployees ing reliance on technical partners and how these need a strong financial background rather than focusing relationships are financed. On the one hand, if the on a background in development or field experience. This Global Fund is not going to develop its own technical was linked to the discussion about the Global Fund’s capacity, it has to be able to rely on useful, helpful, ac- quickness to remind that “we are a funder, not a devel- tionable guidance from the partners and I think that has opment agency.” This contributes to the perception the been a real problem (GFBoard2). Furthermore, Multilateral2 voiced, Global Fund tends to be obsessed with financial technicalities. The big problem has been basically from the creation The Global Fund reportedly uses effective coordin- of the Fund that technical partners are very important; ation as a criterion for grant approval. The success of the they are the ones who are present on the ground … And application for Phase II of Round 9’s grants for HIV/ many of the countries depend on the technical assistance AIDS and malaria was contingent upon the coordination and the guidance from these technical partners. … It among partners. So, effective coordination among part- works already quite well in some countries and less well ners is recognized as a potential weakness in in others. And the challenge is to get more consistent, let’s Mozambique (Coordination1). However, as there is no say, quality of technical assistance provided by these country presence, the Global Fund itself doesn’t partici- partners (GFSecretariat1). pate in coordination bodies. Engagement with the Health Partners Group would greatly enhance the Glo- Discussion bal Fund’s understanding of country-level activities as History of the Global Fund in Mozambique this coordination body is a clearing house of what each Mozambique first received Global Fund support in partner is doing (OECDPartner3). Round 2 (year 2004) for all three diseases. The Global Warren et al. Globalization and Health (2017) 13:89 Page 7 of 14 Fund signed Mozambique’sfirst Memorandum of The Global Fund paradigm Understanding (MoU) for the sector-wide approach, The Global Fund highly values recipient ownership in the PROSAUDE basket fund. It channelled resources program development, implementation, and evaluation through the basket until the audit of Round 7. Due [40]. The PR leads grant application, administers funds, to problems with reporting and tracing expenditure, develops their targets for performance-based funding, the Global Fund paused funding for Round 8 (year and tracks results [41]. Due to this emphasis on country 2008) [36–39]. Meanwhile the second PROSAUDE ownership, the Global Fund operates without country MoU was released; the Global Fund did not sign. offices [42]. Communication with the Global Fund is en- The Round 8 grant expired while awaiting results of tirely dependent on country teams. Often the PR seeks the OIG’s Round 7 audit. Continued support during technical assistance, particularly for grant application the audit would have required a parallel system for and evaluating performance [43]. Additionally recipients operation. Interviewees gave different accounts of the are typically supported, to some degree, by development audit. Those who work closely with the Global Fund partners on the ground [44]. Bilateral agencies working described it very matter-of-factly. To paraphrase: It in the country provide support, some more than others, was initially claimed that US$14 million was un- because they also have vested interest in Global Fund’s accounted for, but after one year, the audit deemed success as they are donors to the Global Fund [45]. US$1 million missing. This is not surprising given the The Global Fund is a financier, rather than an imple- nature of pooled funding. Eventually the government menting/development agency. Along with other global repaid the US$1 million (OECDPartner1). But one health initiatives created in the early 2000s, it was de- interviewee from a bilateral agency was more cutting signed to overcome market and public failures in inter- in response, national public health, as well as disperse the power of the UN and its agencies [46–48]. It was meant to offer In standard auditing protocol, the organization would streamlined, less bureaucratic, processes. Respondents in be given three months to provide proper evidence for Mozambique suggested that the Global Fund currently spending. The Global Fund gave three months, three functions somewhere between its predecessors and the times. … This is not good practice. The Global Fund hid vision of its creators. behind its procedures. They did not grant access to their draft reports even though they audited bilateral funding The Global Fund has straddled between a managerial by nature of auditing pooled funding. This is not a and a bureaucratic model in Mozambique. They try to healthy approach. They are not improving health or a apply performance-based financing, but their grant man- health sector when covering up results this way agement processes have been highly bureaucratic. They (OECDPartner10). function as a bureaucracy, but they’d like to have performance-based targets (OECDPartner1). Three years after the audit, the Round 8 Health System Strengthening grant was re-constituted in June The cost of the bureaucracy extends beyond cumber- 2012. The Ministry of Health is the principle recipi- some administrative processes … [s]o much money spent ent, and the grant focuses on risk mitigation and on managing and getting through the bureaucratic re- reporting as per the OIG’s report. Despite the Global quirements of the Global Fund (OECDPartner1). Fund reforms in application processes, [the grant pro- Despite respondents’ concerns, they were hopeful posal] went through the old bureaucratic processes about prospective changes with the New Funding Model, (OECDPartner1). and more importantly about the capacity of the Global In Mozambique the audit, requirements for financial Fund to reform at all. The Global Fund’s New Funding management, and performance-based approach, have in- Model addresses inefficiency concerns, and the recent spired questions about Global Fund’s paradigm given the changes in the Global Fund have shown how contexts in which it works. One quote in particular international organizations are capable of re-inventing encapsulates many of the concerns addressed piece-meal themselves (GFCountryStructure2). in other interviews. The Global Fund’s reform is unique for a large-scale organization [49, 50], and respondents seemed to be The Global Fund has two choices: either continue to providing constructive criticism with the hope that feed- not have people on the ground or relax their require- back would result in further reform of the Global Fund. ments for monitoring and evaluation. As it stands there is no one on the ground, they maintain their high expec- Performance-based funding tations, and have other partners doing their monitoring Results-based financing is an attempt to link financial for them (OECDPartner2). input to health-related outcomes. Development partners Warren et al. Globalization and Health (2017) 13:89 Page 8 of 14 compare the results of the funded project or program to of paperwork to fill out … All data that is not aggregated pre-determined targets for a set of indicators. Although in the routine national health information system must be this approach is not new, there is a broader range of ac- gathered in the programme (GFCountryStructure4). tors using a wider range of results-based models. If im- Multilateral3 shared that Mozambique has performed well plemented properly, results-based finance can: align and accomplished targets despite the obstacles posed by donor and recipient objectives, improve data reliability, Global Fund requirements. give recipients a stake in the outcome of their efforts, Mozambique does not necessarily have the financial and give recipients greater discretion and authority to management capacity required to satisfy Global Fund carry out their tasks [51]. On the other hand there are demands, and this directly affects return-on-investment concerns about the effectiveness of these tools for health measurements. Additionally, addressing the obstacles development [52] and the feasibility of measuring out- identified in the performance evaluation would require comes of complex, system-level interventions [53, 54]. systems support. To date, studies have focused on approaches that focus on paying for the results achieved by individuals or insti- They give more money than such a weak system can tutions (for example, health facilities or central medical properly absorb. So overall they might be doing more stores). There has only been one study on results-based harm than good. Giving such a large sum of money with- approaches to grant management [37]. out the proper checks and balances leads to corruption Performance-based finance (PBF) is one of the guiding and growing inequality (OECDPartner10). principles of the Global Fund; continued support for re- cipients depends on proven results. Their strategy to Mozambique is not alone in this. Low absorption “actively manage grants based on impact, value for capacity has been blamed for the failure of many devel- money and risk” includes increased emphasis on impact opment assistance projects in African countries. Donor of funding, investment in data systems, requirement of agencies complain that insufficient physical infrastruc- increased financial management transparency, coordin- ture and technical expertise at the local level generate ation with recipients and other donors, and avoidance of high transaction costs and, thus, inefficiency in project duplicated or inconsistent demands on recipients [55]. implementation. Distribution and institutional channels GFSecretariat2 shared that the organization uses a in Mozambique are weak and thus the US government more progressive model of PBF than a strictly results- takes a hegemonic approach (GFCountryStructure2). based approach. Currently the approach centers upon The managerial needs of aid administration and imple- progress and improved performance of national pro- mentation are often overlooked. This leads, among grams. They focus on country ownership of results and others, to slow delivery of assistance and reporting prob- corrective actions. The Global Fund wants to understand lems [56–59]. why a country is not performing, not just where the Based on the interviews in Mozambique, it is difficult money is going. Part of this decision-making is to get to know if the intention of the Global Fund’s PBF has countries themselves to do their own performance re- been communicated on the ground, or if it’s been over- views. So part of it is not just the mechanical rating, it’s shadowed by the administrative burden placed on the that they actually do review their results against their principle recipient. A Geneva-based interviewee made a targets, and they explain the deviations and they come to comment that implies, to date, headquarters has recog- an overall rating (GFSecretariat2). nized the need for change. [We need to] push down the While this approach is arguably more holistic, it has performance-based funding so that it’s not just done in a been reasoned that the subjective elements of their evalu- committee room in Geneva, but there are these program ation decrease incentives to improve performance [37]. reviews that are done within countries, … we need to in- This conclusion was supported by a development partner vest much more that there’s a process in-country, and in Mozambique. The recipients’ criterion for success is dis- performance-based at the country level (GFSecretariat2). bursement rather than results (OECDPartner10). Until countries take full ownership of this process and The Global Fund approach was described as a stream- are empowered by the intended purpose of lined skeleton which countries built upon to create their performance-based financing, PBF will likely continue to own performance evaluation. …we had several hundred be perceived as an administrative burden and identified indicators and we’ve reduced it down to a top set of 10, as a siloed donor demand. which are highly weighted, but then a country can use fur- ther indicators. They have to set targets, and then it’s really Country oversight how many of those targets are reached (GFSecretariat2). The Global Fund does not have country offices. Instead But concerns at the country-level focus on burdens placed they rely on country teams that are based in Geneva, on data collection systems. There is an enormous amount travel to the country, and are led by a Fund Portfolio Warren et al. Globalization and Health (2017) 13:89 Page 9 of 14 Manager with support from 3rd party Local Fund In-country coordination Agents at country level. The team is comprised of Coordination among donors is central to the programme officers, and legal, procurement, finance, harmonization pillar of the Paris Declaration as one of and M&E staff [60]. Team members are responsible for three principles to avoid duplication [61]. Mozambique multiple countries. Previously country teams typically has a Health Partners Group that meets monthly and visited Mozambique once annually, but with the changes brings together all health sector supporters, including under the New Funding Model, teams visit countries representatives of civil society. In 2008 Mozambique multiple times per year (Multilateral4; OECDPartner2). signed an International Health Partnership (IHP+) com- This increase in frequency has yielded mixed reviews. pact [62]. It is a commitment among partners to Many respondents saw it as an improvement because harmonize and align their support with nationally de- the country teams are becoming more familiar with the fined priorities (to the extent that their procedures realities on the ground and are available for guidance. allow). A Global Fund Board Member identified IHP+ as One respondent contradicted this feedback. Countries the most important opening that we have right now also complain that country teams come too often. There (GFBoard3) for increased coordination and collaboration is not enough time to make progress between visits, they with other development partners. are constantly working for the next visit, and this in- Many more coordinating bodies have been created in creases the time stress (GFSecretariat5). Overall, the Mozambique as a result of absorption challenges. These major concerns voiced by respondents were that country include the G19 (a group of bilateral donors who pro- teams are over-worked and are therefore sometimes un- vide sector-wide support and coordinate among them- successful as the channel for communication, too much selves), the National AIDS Council (Conselho Nacional depends on an individual (the Fund Portfolio Manager), Contra o SIDA), NAIMA+ (NGOs coordinating body), and the country teams are out of touch with the realities etc. As one donor representative put it, [the coordinat- on the ground. ing bodies] in Mozambique they are a nickel a dozen! Aside from technical support for proposal develop- This is due to a very weak civil society. If you get an or- ment and grant implementation, country teams act as ganogram of the Ministry of Health, you will see so many the primary channel of communication with Global directors and sub-directors, but not many technicians Fund headquarters. The Global Fund does not put things (GFCountryStructure2). on their website to communicate widely with stake- This has led to conventional donors and local officials holders, including at the country level. They rely on Fund spending exorbitant time on coordination, rather than Portfolio Managers and people on the country team on implementation issues. Coordination among different (NGO1). Interviewees in-country and in Geneva ‘market players’ involves notably high transaction costs expressed concern about the reliance on country teams. [58]. Yet, integration into a single organization with uni- The availability of expertise within the team is country- fied goals involves either high bureaucracy costs [63] or dependent. … Personnel are over-worked and over- requires very strong leadership [64]. extended and as a result it is not uncommon for them to All respondents who represent the Global Fund agreed take extended leave. This has caused detrimental gaps in that coordination at the country-level is vital for success- communication (GFCountryStructure1). The Global ful implementation. A member of the Secretariat com- Fund has recognized some of the issues associated with mented on coordination as if it is integral to the nature the burden placed on country teams and has begun to of the Global Fund’s engagement. We are a contribution bring in technical expertise to help (GFSecretariat5). model and impact only really occurs when you’ve got One Board Member emphasized the importance of in- other donors in the national program also contributing creasing coordination with other development partners (GFSecretariat2). The picture painted by most country- in-country to address shortcomings of the country team. level respondents was very different. Only one partici- The Global Fund is currently doing stakeholder mapping pant suggested that s/he was satisfied with the Global at the country level so that the network of partners is Fund’s influence on country-level coordination. Pro- clear. For now, at least, country teams are staffed with grammatically they brought a new approach. They forced very bright people that regularly visit the country partners to coordinate more (Multilateral2). Decision- (GFBoard5). GFBoard2 suggested that some of these makers at the Global Fund did voice the need for concerns could be addressed with clearer expectations improvement. Few specifically mentioned country-level for a Fund Portfolio Manager and more effective coord- coordinating bodies, but they recognized that the only ination among constituents. Essentially, there needs to way to avoid duplication is through coordinating with be changes in the hiring of Fund Portfolio Managers other actors. There’s definitely more to be done. Fortu- combined with diffused powers in oversight of grant nately, it’s moving in the right direction. It’s crazy to think implementation. you can do appropriate due diligence of a proposal for Warren et al. Globalization and Health (2017) 13:89 Page 10 of 14 funding to the Global Fund if you don’t understand what the most involved of all the Global Fund donors both fi- other people are already funding (GFBoard2). Overall nancially but also in terms of coordination at the respondents expressed frustration about the Global project-level. All of Global Fund’s activities on the ground Fund’s lack of coordination; this was a near-universal in Mozambique are coordinated with PEPFAR and the theme at the country-level. This was mirrored by President’s Malaria Initiative [PMI] (OECDPartner6). GFCountryStructure1’s reflection that the main criticism during the rounds-based model- the lack of coordination In Mozambique the US government even has a Global with in-country partners. Fund Liaison on the payroll. This position was created The Global Fund’s challenges with coordination are not to increase coordination of Global Fund with PEPFAR unique among implementing agencies in any field of de- and [PMI] The position is pay-rolled by USAID, PEPFAR, velopment nor is Mozambique’s ineffective coordination or US Centers for Disease Control [CDC] depending on unique among recipient countries (manuscript in prepar- the country (OECDPartner1). Respondents expressed ation). Rather these challenges are symptomatic of a confidence in the liaison and saw the position as the best widespread trend in development assistance in most window into Global Fund support. One interviewee con- sectors [65, 66]. trasted it with the intended mechanism of coordination. Partnerships The Global Fund liaison is more effective than the The two largest donors to the Global Fund, the United Country Coordinating Mechanism because the members States and France, both contribute 5 % of their pledges of the [CCM] are not actually paid; if the [CCM] were to to technical assistance (TA) [3]. The 5 % is channelled become institutionalized, it would result in a parallel through their bilateral development agencies or their re- system (Multilateral5). spective technical bodies founded to support Global Fund principle recipients- Grant Management Solutions This degree of support from the US government has and Initiative 5% [67, 68]. Information, personnel, been invaluable in Mozambique. They are able to identify finance, equipment, and supplies are all forms of TA for gaps early on and provide additional support as needed. which applicants are eligible [69]. The latest published The National HIV/AIDS Acceleration Plan [financed by list of providers of technical assistance was in 2004 [69]. the Global Fund] … is projected to have a massive gap in At the time there were 170 Global Fund-related tech- commodities procurement, which the US government will nical assistance providers (135 organizations and 35 ultimately need to fill (OECDPartner6). But interviewees technically-qualified individuals). At the time of writing, also shared concerns of when the agenda of the US gov- the Global Fund website listed six organizations that ernment and the other donors do not align. offer TA. Aside from requests for technical cooperation on community, rights, and gender issues, the Global US Congress sets specific targets … that make it im- Fund encourages direct contact with TA providers [43]. perative for US development activities to follow their own The consultants hired to advise countries on strategies goals. Otherwise Congress will cut funding. … US funding for their concept note development are paid by the part- has far more constraints and accountability rules, so that ners. … There is a lot of money flowing for Global Fund little of it goes directly to the Mozambican government. engagement that is not accounted for. … These activities PEPFAR has a more efficient implementation machine, are coordinated at the country level, at the Development but –indeed—perhaps the long-term coordination suffers Partners Group (GFBoard4). (GFCountryStructure2). Interviews in Mozambique revealed that partners do more than provide TA, they also step in to fill gaps. This response was independently supported by other When there are delays / gaps with the Global Fund, interviewees (OECDPartners 2 and 3) who touched upon other donors step in for support. The other donors’ re- donor relations in Mozambique and the disagreement sponses are not formally decided or premeditated among the G19 about expectations to hold. (OECDPartner6). The US government is the largest donor in the health sector; they provide more develop- US government recognizes that Mozambique has weak ment assistance for health than all other donors com- systems and provides support for the system so as not to bined (GFCountryStructure2). They often fill gaps in set them up to fail but expects them to be a genuine part- Global Fund support due to the fact that they are both ner and makes changes based on lessons learned. The Mozambique’s and the Global Fund’s largest investor. Global Fund expects the Ministry of Health to apply for funds and then take a “do-it-yourself” approach to The US government is very invested in Mozambique’s systems strengthening, but this fails because they need success with the Global Fund … The US government is support (OECDPartner2). Warren et al. Globalization and Health (2017) 13:89 Page 11 of 14 Some partners question the boundary between the US example, the WHO, to address stringent performance- government and the Global Fund. In Mozambique criti- based funding reporting requirements. Additionally they cizing the Global Fund is criticizing US government as- require buttressing by bilateral donors who provide fi- sistance (OECDPartner10). Based on discussions with nance to the Global Fund and the countries in which it Board Members in Geneva about partners providing operates, for example, the US government (Table 2). TA on the ground, this concern extends up to the highest levels and is perhaps not unique to Mozambique. Ability to reform A member of the Secretariat reinforced the prospect Overall, there were mixed reviews on what the New that there is enmeshment of Global Fund and US Funding Model has, or will, actually change on the government agendas at the highest level. When asked if ground, but multiple interviewees referred to the Global Global Fund’s donors are coordinating to maximize their Fund’s ability to reform as one of the defining character- contributions the interviewee only discussed coordin- istics of the organization. It was a prominent, recurring ation with the US government (USG). The Global Fund theme in interviews. has formed a partnership with PEPFAR to avoid duplica- tion. … The USG focuses on service delivery and “Global Fund has proved in 10 years to have the abil- community-level interventions, and the Global Fund ity to renew itself” (Multilateral4). works at the national level (GFSecretariat5). It is unclear from GFSecretariat5’s response at what level the US gov- “The Global Fund’s New Funding Model addresses ernment is supposed to share knowledge, and with inefficiency concerns, and the recent changes in the whom exactly. Global Fund have shown how international The degree of external support required for the Global organizations are capable of re-inventing themselves” Fund’s success has raised a debate on accountability. To (GFCountryStructure2). whom are the providers of TA held accountable?… the most difficult part of the Global Fund model is the part- “Overall, the Global Fund is learning from its mistakes. nership model. It depends on the support of partners and … the Global Fund, completed its reformation in one yet it doesn’t have any say over the partners. … I think year. It is a ‘learning organization’; it is navigating we need to figure out what that relationship should be through a field of opposing forces, and is highly commit- (GFBoard2). ted to its mission” (GFBoard4). In Mozambique this blurry line extends to the Minis- try of Health. The US government pays for the Global Although many of the reforms have not yet addressed Fund Unit in the Ministry of Health (OECDPartner6). concerns about the Global Fund’s overall model, inter- It’s in the Department of Planning and Coordination and viewees seemed to be looking beyond this initial trans- is responsible for coordinating Global Fund projects. In formation. They clarified that although their responses terms of coordination, the US government is the only bi- were critical of the Global Fund, they admire the Fund’s lateral donor that [the Global Fund Unit] has contact work (GFBoard4 and GFBoard5). This sentiment is with (GFCountryStructure4). linked to the organization’s ability to reform- respon- A new channel was created to manage Global Fund dents can use opportunities such as interviews to share money in 2010/11 in response to the Global Fund’s lessons learned about perceived strengths and weak- withdrawal from the health financing basket. Rather nesses of the Global Fund with the hope that they are than going directly from the Ministry of Finance to included in the next wave of changes. the Ministry of Health, money goes through the Global Fund Unit. The combination of burdensome “I think there is commitment from the Secretariat as requirements and weak oversight has resulted in the well certainly from our constituency and others to im- need for an entire unit within the Ministry of Health. prove the Funding Model. As Mark Dybul is the first to Mozambique is an example of a country undergoing say, ‘we haven’t got it all right’, this will be an iterative internal reform of reporting systems to adapt to Glo- process to continuously improve how the new funding bal Fund requirements (GFBoard4). The fact that it is model works” (GFBoard2). paid for by the US government means that it is ac- countable to the US government and not the Mozam- As one respondent pointed out, the continued success bican government. of the Global Fund in Mozambique is important because The Global Fund’s lack of country presence results in the Global Fund is a means of getting around the govern- inadequate coordination with in-country partners. It also ment; the government does not necessarily reflect societal necessitates support from technical partners, for demands (OECDPartner3). Warren et al. Globalization and Health (2017) 13:89 Page 12 of 14 Conclusions Além disso, os tomadores de decisão em Genebra recon- In Mozambique the Global Fund is viewed as an institu- hecem que a coordenação local é necessária para a tion that is uniquely capable of reform. Despite the implementação bem-sucedida; outros parceiros locais changes with application processes that are associated apreciariam o envolvimento do Fundo Global. Até agora, with the New Funding Model, respondents in both não há requisitos institucionais para a coordenação for- Geneva and Maputo firmly believed that challenges re- malizada e, no momento das entrevistas, o Fundo Global main in the inherent structure and paradigm of the não tinha uma representação consistente em nenhum Global Fund. The lack of a country office has many dos grupos de coordenação no país. negative downstream effects including reliance on part- Embora a decisão do Fundo Global de não ter escritórios ners in-country. Due to weak managerial and absorptive locais possa ser justificada, as dificuldades locais sugerem capacity, more oversight is required than is afforded by que o Fundo Global deve adoptar uma abordagem mais country team visits. In-country partners provide much consciente, adaptando os mecanismos de subvenção e os needed support for Global Fund recipients, but roles, re- procedimentos de monitoramento às realidades locais. sponsibilities, and accountability must be clearly defined Deve-se estabelecer regras que sejam flexiveis e simultânea- for a successful long-term partnership paradigm. Fur- mente respeitem as demandas da sede central. Isso desloca thermore, decision-makers in Geneva recognize in- para a sede central a responsabilidade de avaliar se os rela- country coordination as vital to successful implementa- tórios dos países cumprem as exigências. O Fundo Global tion, and other actors in-country would welcome Global poderia associar essas mudanças com uma política mais Fund engagement. To date, there are no institutional re- formalizada de coordenação no país. quirements for formalized coordination, and at the time of the interviews the Global Fund has no consistent Take-home messages representation in any in-country coordination groups The lack of a country office has many negative despite its focus on performance-based finance. downstream effects including over-reliance on part- Although the Global Fund’s decision against having ners in-country. local offices in order to encourage local ownership may Although partnerships provide much needed be justified, the various downstream difficulties suggest support for Global Fund recipients, roles, that the Global Fund should adopt a more conscientious responsibilities, and accountability must be clearly approach by adapting grant implementation and moni- defined for a successful long-term partnership. toring procedures to the specific local realities. It should The Global Fund emphasizes coordination at the establish procedures that allow room for flexibility while higher levels of the organization, but country teams’ remaining harmonized with headquarter demands. This engagement with other actors in-country is shifts the onus to headquarters to assess whether what a dependent on the Fund Portfolio Manager. country reports meets the requirement. The Global The Global Fund’s ability to reform is seen as Fund could couple these changes with a policy for for- unique, and respondents see its approach as malized coordination in-country. continually evolving. Additional Portuguese conclusions Mensagens principais Em Moçambique o Fundo Global é visto como uma  A ausência de um escritório no pais tem causado instituição que é particularmente capaz de se reformar. muitos efeitos negativos, incluindo a dependência do Apesar das mudanças nos processos de solicitação asso- Fundo em parceiros locais. ciados como o Novo Modelo de Financiamento, os con-  As parcerias acomodam o apoio necessário aos sultados em Genebra e Maputo acreditam firmemente beneficiários do Fundo Global, mas as tarefas, as que ainda permanecem desafios na estrutura inerente e responsabilidades e as prestações de contas devem no paradigma do Fundo Global. A falta de escritórios ser definidas mais claramente para ter uma parceria locais tem muitos efeitos negativos, causando dependên- bem-sucedida a longo prazo. cia em parceiros nacionais. Devido à capacidade fraca de  Fundo Global enfatiza coordenação nos seus níveis gerenciamento e de absorção é necessária mais supervi- mais altos, mas o nível de envolvimento das equipes são da que é possível atualmente nas visitas do gerente dentro de Moçambique com parceiros dentro do de carteira em Genebra. Parceiros em Moçambique for- país depende do gerente de carteira do Fundo. necem apoio aos beneficiários do Fundo, mas as difer-  A capacidade de reforma do Fundo Global pode ser entes tarefas, responsabilidades e prestações de contas vista como uma oportunidade única, e os entrevistados precisam ser definidas mais claramente para chegar a consideram sua abordagem como uma evolução um paradigma de parceria bem-sucedido a longo prazo. continua. Warren et al. Globalization and Health (2017) 13:89 Page 13 of 14 Endnotes Received: 20 February 2017 Accepted: 25 October 2017 These include the next eleven emerging economies, N-11 (Bangladesh, Egypt, Indonesia, Iran, Mexico, Nigeria, Pakistan, the Philippines, Turkey, South Korea and Vietnam). References 1. Sherry J, et al. The Five-Year Evaluation of the Global Fund to Fight AIDS, Jakovljevic M, et al. BRICS VS. N-11. In: Health Economics Tuberculosis, and Malaria: Synthesis of Study Areas 1, 2, and 3. 2009, macro and Policy Challenges in Global Emerging Markets. Jakovlje- international. In: . MD; USA: Calverton. vic M, editor. New York: Nova Science Publishers, Inc.; 2. Biesma R, et al. The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan. 2016: 1–18. ISBN 978–1–63,484-720-9 (eBook). 2009;24(4):239–52. 3. The Global Fund. Pledges and Contributions. 2016; Available from: http://www. Additional file theglobalfund.org/documents/core/financial/Core_PledgesContributions_List_en/. 4. The Global Fund. Financials. How We Work 2016 [cited 2015 26 October]; Available from: http://theglobalfund.org/en/financials. Additional file 1: Semi-structured interview guide. (DOCX 20 kb) 5. IHME. Viz Hub: Financing Global Health. 2016 [cited 2016 8 November]; Available from: http://vizhub.healthdata.org/fgh/. Abbreviations 6. Clinton C, Sridhar D. WHO pays for cooperation in global health? A CCM: Country Coordinating Mechanism; CDC: US Centers for Disease Control; comparative analysis of WHO, the World Bank, the Global Fund to fight HIV/ HSS: Health systems strengthening; IHP: + International Health Partnership; AIDS, tuberculosis and malaria, and Gavi, the vaccine alliance. Lancet. LFA: Local Fund Agent; M&E: Monitoring and evaluation; MDG: Millennium 2017;390(10091):324–32. Development Goal; MoU: Memorandum of Understanding; NFM: New 7. The Global Fund. Overview. How We Work 2016 [cited 2015 25 October]; Funding Model; NGO: Non-governmental organization; OECD: Organization Available from: http://theglobalfund.org/eng/overview/. for Economic Cooperation and Development; OIG: Office of the Inspector 8. The Global Fund, The Global Fund Governance Handbook. 2014, The Global General; PBF: Performance-based finance; PEPFAR: the US President’s Fund: Geneva, Switzerland. Emergency Plan for AIDS Relief; PMI: the US President’s Malaria Initiative; 9. The Global Fund, Operation Policy Manual. 2016, The Global Fund: Geneva, PR: Principle Recipient; TA: Technical assistance; TRP: Technical Review Panel; Switzerland. USAID: US Agency for International Development 10. The Global Fund. Donors commit US$11.7 billion to the Global Fund for next three years. News & Stories 2010 [cited 2015 26 October]; Available Acknowledgements from: http://www.theglobalfund.org/en/news/2010-10-05_Donors_commit_ The authors would like to thank all participants for their time and interest in USD_11_7_Billion_to_the_Global_Fund_for_next_three_years/. responding to interviews and follow-up. The authors would also like to thank 11. The Global Fund. The Global Fund confirms freeze on cash disbursements Stephen Browne, Prof. Raymond Saner, Lichia Yiu, and Shufang Zhang for their to Zambia Ministry of Health, grants to be transferred to UNDP. News & contributions to this research by conducting interviews through the SNIS project. Stories 2010 [cited 2015 26 October]; Available from: http://www. We would also like to thank Olivia Meira and Giovanna Centeno Barbalho for theglobalfund.org/en/news/2010-06-16_Global_Fund_confirms_freeze_on_ translating the abstract, conclusions, and take-home messages into Portuguese. cash_disbursements_to_Zambia_Ministry_Of_Health_grants_to_be_ transferred_to_UNDP/. Funding 12. The Global Fund. Global Fund suspends grants to Philippines foundation. This work was funded by the Swiss Network for International Studies News & Stories 2009 [cited 2015 26 October]; Available from: http://www. (reference # 3938) and the Swiss Tropical and Public Health Institute. theglobalfund.org/en/news/2009-09-24_Global_Fund_suspends_grants_to_ Philippines_foundation/. 13. The Global Fund. Global Fund suspends grant to the Executive Secretariat Availability of data and materials of the National AIDS Committee in Mauritania. News & Stories 2009 [cited Not applicable. 2015 26 October]; Available from: http://www.theglobalfund.org/en/news/ 2009-09-09_Global_Fund_suspends_grant_to_the_Executive_Secretariat_of_ Authors’ contributions the_National_AIDS_Committee_in_Mauritania/. AW conceived of the content and prepared the manuscript. AW, RC, and 14. The Global Fund - OIG, The Office of the Inspector General Progress Report DdS edited drafts of the manuscript. All authors read and approved the final for March–October 2010 and 2011 Audit Plan and Budget, Office of the manuscript. Inspector General, Editor. 2010, The Global Fund: Geneva, Switzerland. 15. Heilprin, J., Fraud plagues global health fund, in The Guardian. 2011: London, U.K. Ethics approval and consent to participate 16. Rivers B, Corruption by Global Fund Grant Implementers, in Global Fund The Ethikkommission beider Basel EKBB approved the research protocol on Observer 139. Aidspan: Nairobi. Kenya. 2011; 21 Oktober 2013 (# 288/13). 17. The Global Fund. Independent review of the Global Fund will be concluded by September. News & Stories 2011 [cited 2015 26 October]; Available from: Consent for publication http://www.theglobalfund.org/en/news/2011-05-04_Independent_review_ Not applicable. of_the_Global_Fund_will_be_concluded_by_September/. 18. The Global Fund. The Global Fund Board meets to consider 5-year strategy, Competing interests reform agenda. News & Stories 2011 [cited 2015 26 October]; Available DdS is a member of the Global Fund Technical Evaluation Reference Group (TERG). from: http://www.theglobalfund.org/en/news/2011-05-10_The_Global_ Fund_Board_meets_to_consider_5-year_strategy_reform_agenda/. Publisher’sNote 19. The Global Fund, Global Fund Board adopts Panel recommendations calling Springer Nature remains neutral with regard to jurisdictional claims in for urgent reform. 2011. published maps and institutional affiliations. 20. The Global Fund. The Global Fund's Executive Director to step down in March. News & Stories 2012 [cited 2015 26 October]; Available from: http:// Author details www.theglobalfund.org/en/news/2012-01-24_The_Global_Fund_Executive_ Department of Epidemiology and Public Health, Swiss Tropical and Public Director_to_step_down_in_March/. Health Institute, Socinstrasse 57, 4002 Basel, Switzerland. University of Basel, 21. The Global Fund. The Global Fund appoints Gabriel Jaramillo as General Petersplatz 1, 4003 Basel, Switzerland. Franklin University Switzerland, Via Manager: New Position Created to Implement the Organization's Ponte Tresa 29, 6924 Lugano-Sorengo, Switzerland. Graduate Institute of Transformation Plan. News & Stories 2012 [cited 2015 26 October]; Available International and Development Studies, Maison de la Paix, Chemin from: http://www.theglobalfund.org/en/news/2012-01-24_The_Global_ Eugène-Rigot 2, 1202 Geneva, Switzerland. Fund_appoints_Gabriel_Jaramillo_as_General_Manager/. Warren et al. Globalization and Health (2017) 13:89 Page 14 of 14 22. Harvard T.H. Chan School of Public Health. Gabriel Jaramillo, former General 45. van Kerkhoff, L. and N.A. Szlezak, The role of innovative global institutions in Manager of The Global Fund. 2014 [cited 2016 15 September]; Available linking knowledge and action. Proc Natl Acad Sci U S A, 2016. 113(17): p. from: https://www.hsph.harvard.edu/voices/events/jaramillo/. 4603–4608. 23. Garmaise, D., Global Fund Releases Report on Losses and Recoveries, Global 46. Buse K, Walt G. Global public-private partnerships: part I–A new Fund Observer, Editor. 2013, Aidspan: Nairobi, Kenya. development in health? Bull World Health Organ. 2000;78(4):549–61. 47. Greenall M, et al. Reaching vulnerable populations: lessons from the Global 24. The Global Fund. Grant Portfolio. Where We Invest 2016 [cited 2015 25 Fund to Fight AIDS, Tuberculosis and Malaria. Bull World Health Organ. October]; Available from: http://www.theglobalfund.org/en/portfolio/. 2017;95(2):159–61. 25. The Global Fund. Funding Model. How We Work 2016 [cited 2015 26 48. Kunii O, Yassin MA, Wandwalo E. Investing to end epidemics: the role of the October]; Available from: http://www.theglobalfund.org/en/fundingmodel/. Global Fund to control TB by 2030. Trans R Soc Trop Med Hyg. 26. The Global Fund, The Global Fund's New Funding Model, in The Global 2016;110(3):153–4. Fund to Fight AIDS, Tuberculosis and Malaria: Fourth Replenishment (2014- 49. Hanrieder T. The Reform Reformation: International Organizations and the 2016). 2013, the Global Fund: Geneva, Switzerland. Challenge of Change, in Council on. Foreign Affairs. 2016; https://www. 27. The Global Fund - OIG, Audit of Global Fund Grants to the Republic of foreignaffairs.com/articles/2016-04-08/reform-reformation Mozambique, Office of the Inspector General (OIG), Editor. 2012, The Global 50. Kelland, K., The World Health Organization’s critical challenge: healing itself, Fund: Geneva, Switzerland. in Reuters Investigates. 2016: http://www.reuters.com/investigates/special- 28. The Global Fund. MOZ-202-G03-M-00 : Building Capacity to Scale Up Roll report/health-who-future/. Back Malaria in Mozambique. Grant Portfolio 2016 [cited 2015 26 October]; 51. Savedoff WD. Basic economics of results-based financing in health. Bath, Available from: http://theglobalfund.org/en/portfolio/country/grant/?k= Maine: Social Insight; 2010. 8dacfcaf-f44c-474f-af34-3200847b2b54&grant=MOZ-202-G03-M-00. 52. Oxman AD, Fretheim A. Can paying for results help to achieve the 29. The Global Fund. MOZ-202-G04-T-00 : Strengthening and expanding TB millennium development goals? Overview of the effectiveness of results- services in Mozambique. Grant Portfolio 2016 [cited 2015 26 October]; based financing. J Evid Based Med. 2009;2(2):70–83. Available from: http://theglobalfund.org/en/portfolio/country/grant/?k= 53. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a 29c2ec6e-85d5-4cad-99a2-d6c942b3ff07&grant=MOZ-202-G04-T-00. donor fad or a catalyst towards comprehensive health-care reform? Bull 30. The Global Fund. MOZ-607-G05-H : Mozambican Initiative to expand World Health Organ. 2011;89(2):153–6. coverage for prevention, care, support and treatment for people affected by 54. de Savigny D, Adam T. Systmes thinking for health systems strengthening. HIV/AIDS. Grant Portfolio 2016 [cited 2015 25 October]; Available from: Geneva, Switzerland: World Health Organization; 2009. http://theglobalfund.org/en/portfolio/country/grant/?k=3c9cdfd9-7517-4b8f- 55. The Global Fund. The Global Fund strategy 2012–2016: investing for impact. a41c-b5da94ab8796&grant=MOZ-607-G05-H. Geneva, Switzerland: The Global Fund to Fight AIDS, Tuberculosis and 31. The Global Fund. MOZ-708-G07-T : Reducing Tuberculosis Morbidity and Malaria; 2012. Mortality in Mozambique by 2012, through strengthening of the National 56. Austin, J.E., Managing in Developing Countries: Strategic Analysis and Tuberculosis Control Program at all levels. Grant Portfolio 2016 [cited 2015 Operating Techniques. 1990, New York, NY: The Free Press: a division of 25 October]; Available from: http://theglobalfund.org/en/portfolio/country/ Macmillan. grant/?k=bc98b2e4-5c3c-4cfc-95d5-b8cf8e8a727b&grant=MOZ-708-G07-T. 57. Easterly W. The tyranny of experts: economists, dictators and the forgotten 32. The Global Fund. MOZ-911-G10-H : Responding to the HIV epidemic in rights of the poor. New York, NY: Basic Books; 2013. Mozambique through effective government - civil society partnerships. 58. Coase RH. The nature of the firm. Economica, New Series. 1937;4(16):386–405. Grant Portfolio 2016 [cited 2015 26 October]; Available from: http:// 59. Simon HA. Administrative behavior: a study of decision-making processes in theglobalfund.org/en/portfolio/country/grant/?k=cc45cd7f-6744-4689-af93- administrative organizations. New York, NY: The MacMillan Company; 1947. d7c108d50a8c&grant=MOZ-911-G10-H. 60. Garmaise, D., New "Country Team Approach" Adopted for Managing Grants, 33. SNIS. Trends and Influence of Private Finance on Global Health Initiatives Global Fund Observer, Editor. 2010, Aidspan: Nairobi, Kenya p 8-9. and Development Goals in Resource-constrained Countries. 2012 [cited 61. OECD, Paris Declaration on Aid Effectiveness. Organization for economic 2016 10 October]; Available from: http://www.snis.ch/project_trends-and- co-operation and development (OECD). Paris: France; 2005. influence-private-finance-global-health-initiatives-and-development-goals. 62. IHP+, Mozambique Compact, Department of Health Systems Governance 34. Jakovljevic MB. BRIC's growing share of Global Health spending and their and Financing, Editor. 2008, International health partnership, World Health diverging pathways. Front Public Health. 2015;3:135. Organization: Geneva, Switzerland. 35. Gale NK, et al. Using the framework method for the analysis of qualitative 63. Williamson OE. Markets and hierarchies: analysis and antitrust implications. data in multi-disciplinary health research. BMC Med Res Methodol. New York, NY: The Free Press; 1975. 2013;13:117. 64. Selznick P. TVA and the grass roots: a study in the sociology of formal 36. Bridge J, et al. The Global Fund to Fight AIDS, Tuberculosis and Malaria's organization. Berkeley and Los Angeles, CA: University of California Press; 1949. investments in harm reduction through the rounds-based funding model 65. Mwisongo A, Nabyonga-Orem J. Global health initiatives in Africa - (2002-2014). Int J Drug Policy. 2016;27:132–7. governance, priorities, harmonisation and alignment. BMC Health Serv Res. 37. Fan VY, et al. Performance-based financing at the Global Fund to Fight 2016;16(Suppl 4):212. AIDS, Tuberculosis and Malaria: an analysis of grant ratings and funding, 66. Lawson ML. Foreign aid: international donor coordination of development 2003-12. Lancet Glob Health. 2013;1(3):e161–8. assistance. Washington, D.C: Congressional Research Service; 2013. 38. Fan VY, et al. Dedicated health systems strengthening of the Global Fund to fight 67. GMS. Grant Management Solutions. 2016 [cited 2016 10 November]; AIDS, tuberculosis, and malaria: an analysis of grants. Int Health. 2017;9(1):50–7. Available from: http://www.gmsproject.org/gmswebsite/. 39. Kiefer S, et al. Operational and implementation research within Global Fund 68. Initiative 5%. Initiative 5% SIDA, Tuberculose, Plaudisme. 2016 [cited 2015 27 to Fight AIDS, Tuberculosis and Malaria grants: a situation analysis in six July]; Available from: http://www.initiative5pour100.fr/en/frances-commitment/ countries. Glob Health. 2017;13(1):22. france-and-the-global-fund/. 40. Atun R, Kazatchkine M. Promoting country ownership and stewardship of 69. Averett, S. and B. Rivers, The Aidspan Guide to Obtaining Global Fund- health programs: the Global Fund experience. J Acquir Immune Defic Syndr. Related Technical Assistance, Global Fund Observer, Editor. 2004, Aidspan: 2009;52(Suppl 1):S67–8. Nairobi, Kenya. 41. The Global Fund. Implementing Partners. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/implementers/. 42. The Global Fund. Organizational Structure. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/organization/structure/ 43. The Global Fund. Technical Cooperation. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/fundingmodel/ technicalcooperation/. 44. The Global Fund. Technical & Development Partners. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/ technical/#related-resources. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Globalization and Health Springer Journals

The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique

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Springer Journals
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Copyright © 2017 by The Author(s).
Subject
Medicine & Public Health; Public Health; Development Economics; Social Policy; Quality of Life Research; Epidemiology
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1744-8603
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10.1186/s12992-017-0308-7
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29233165
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Abstract

Background: The Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique. Methods: We conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing. Results: Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In- country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in- country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement. Conclusions: To date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination. Resumo O Fundo Global é uma das ONGs mais importantes do mundo quando se trata do desenvolvimento da saúde global. Em 2015 foi desembolsado quase dez por cento de todo o orçamento à assistência no mundo direcionada à saúde. Em 2011, iniciaram um processo de reforma em resposta a alegações do mau uso das doações recebidas. As reformas têm focado no processo de aplicação do dinheiro, já as estruturas da ONG e seu paradigma tem permanecido intactos. Esta análise trata os resultados das discussões sobre o Fundo Global, seu paradigma de supervisão e monitoramento, e (Continued on next page) * Correspondence: ashley.warren@swisstph.ch Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002 Basel, Switzerland University of Basel, Petersplatz 1, 4003 Basel, Switzerland Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Warren et al. Globalization and Health (2017) 13:89 Page 2 of 14 (Continued from previous page) os resultados derivados em Moçambique. Pesquisadores realizaram 37 entrevistas em pessoa e uma entrevista por telefone com 38 partes interessadas em Maputo, Moçambique e membros do Conselho e Secretariado do Fundo Global na Suíça. Os entervistados em Moçambique eram representantes das estruturas locais do Fundo Global (p. ex. destinatários principais), do Ministério da Saúde, e ‘agencias bilaterais ou multilaterais e adidos da saúde ou desenvolvimento de embaixadas parceiras em Moçambique. Foram também incluídos representantes das Nações Unidas, consultores, e coordenadores das ONGs. Codificação temática revelou preocupações quanto à combinação da supervisão fraca no país com os requisitos rigorosos de monitoramento e avaliação; processos que estão conectados ao financiamento baseado em desempenho. A análise revelou que, apesar das mudanças associadas ao New Funding Model (Novo Modelo de Financiamento), a maioria dos consultados, tanto em Genebra como em Maputo, reconhecem que aínda existem desafios na estrutura e no paradigma do Fundo Global. A falta de um escritório em Moçambique tem alguns efeitos negativos, causando dependência em parceiros nacionais e também ineficácia na coordenação. Devido à fraca capacidade de absorção e de gerenciamento no pais, é necessária mais supervisão da que é possível atualmente nas visitas do gerente de carteira em Genebra. Os parceiros em Moçambique fornecem apoio aos beneficiários do Fundo, mas as diferentes tarefas, responsabilidades e prestações de contas precisam ser definidas mais claramente para conseguir uma parceria bem-sucedida a longo prazo. Além disso, os tomadores de decisão em Genebra reconhecem que a coordenação local é imperativa para uma implementação bem-sucedida; os parceiros continuam a apreciar o aumento do envolvimento do Fundo em Moçambique. Atualmente, não existem requisitos institucionais para uma coordenação formal, e o Fundo não tem uma presença continua dentro de grupos de coordenação em Moçambique. O Fundo Global precisa moldar a implementação de projetos e procedimentos de monitoramento às realidades locais que seriam destacadas através de uma coordenação formalizada. Keywords: Global Fund, Mozambique, Financial management, Performance-based finance, Coordination, Country oversight, Reform, New funding model representatives from both donor and recipient countries, Background The Global Fund to Fight AIDS, Tuberculosis, and non-governmental organizations (NGOs), the private Malaria (Global Fund) is a financial instrument estab- sector, and affected communities [8]. The Office of the lished in early 2002 [1]. Its formation was part of the Inspector General (OIG) is an independent body that “emergency response to accelerate the scale-up of con- oversees investment effectiveness including risks associ- trol of the major communicable diseases, especially ated with misused funds. The Technical Review Panel HIV/AIDS” in light of the Millennium Development (TRP) is an independent team of health and develop- Goals (MDGs) [2]. Governments provide approximately ment experts that evaluates proposals submitted to the 95% of Global Fund support; the private sector provides Global Fund [9]. the rest [3]. Since its inception, it has disbursed more The Principle Recipient (PR) is responsible for grant than US$30.6 billion [4]. In 2015, the Global Fund was implementation and can either be part of the public the world’s largest channel of finance for malaria and tu- sector, e.g.aministry,anNGO,or evenaprivate berculosis (40% and 49% of total support, respectively), company. The PR is under the direct supervision of and the second largest channel for HIV/AIDS (16% of the Country Coordinating Mechanism (CCM). The total support). In terms of overall contribution, the Glo- CCM is reflective of the Global Fund’s dedication to bal Fund was responsible for 9 % of funding for global local ownership and decision-making. It writes the health in 2015; it reached its maximum in 2012 and original grant proposal, nominates implementers, and 2013 when it oversaw the disbursement of 12% of the governs grant implementation. The CCM is a partner- total funds dedicated to development assistance for ship of country stakeholders including the private sec- health [5, 6]. tor, academic institutions, multilateral and bilateral The Global Fund has seven core structures, the: Board, development partners, civil society, and key affected Office of the Inspector General, Technical Review Panel, populations [9]. Principle Recipient, Country Coordinating Mechanism, The Global Fund Secretariat is responsible for the Staff / Secretariat, and Local Fund Agent [7]. The Global daily operations, primarily grant management. The Fund Board is the overall governing body responsible for Secretariat engages with Principal Recipients through defining policies, objectives, and strategies. It includes country teams. The Global Fund does not have offices in Warren et al. Globalization and Health (2017) 13:89 Page 3 of 14 recipient countries. Instead it uses Local Fund Agents are determined by countries’ burden of disease and (LFAs) to oversee grant management [9]. ability to finance. This approach is meant to enhance In October 2010 the Global Fund received its largest predictability of funding [25]. replenishment, to date, at US$11.7 billion despite allega- CCMs seek technical assistance to write grants for the tions of illicit use of funds in Zambia, the Philippines, three diseases (and health systems strengthening (HSS) and Mauritania and subsequent freezing of their cash which can either stand alone or be incorporated into a disbursements [10–13]. At the 22nd Board Meeting, the disease-oriented grant). Upon submission, grants are OIG released its Progress Report for March through screened for eligibility by the Secretariat and then passed October 2010. It outlined its findings from investigations along to the TRP which recommends technically sound of allegations of fraud, corruption, and misuse of funds proposals for funding. The Board gives official approval in seven countries [14]. On 23 January 2011, the Associ- of chosen grants. The grants undergo classifications and ated Press published a story, “Fraud Plagues Global budget cuts by the Board before being returned to the Health Fund” [15]. More than 250 media outlets world- TRP for negotiations, further reductions of the budgets wide covered the story and within days Germany froze through efficiency gains, and division between multiple its contribution to the Global Fund [16]. Over the com- PRs (and the subsequent necessary modifications to the ing months the Global Fund underwent independent budget). Then PRs and the Global Fund sign the final review, re-visited its 5-year strategy, and committed to grant agreement The most notable change in the NFM urgent reform [17–19]. Within one year, its Executive is that from the beginning, country teams are engaged in Director, Michel Kazatchkine, announced that he would country-level dialog on concept note development step down, cutting his tenure two years short [17, 20]. (Fig. 1). Gabriel Jaramillo, former Chairman and Chief Executive Officer of Sovereign Bank, was appointed as General Manager to oversee the transformation plan [21]. Mr. The Global Fund in Mozambique Jaramillo lacked technical expertise in health develop- As of 2016, Mozambique has been awarded 17 grants. ment, but he specialized in managing change in complex The Global Fund signed, committed, and disbursed a financial institutions during his 36 years of experience in total of more than US$972 million, US$802 million, and banking in Latin and South America and the US [22]. US$620 million, respectively, to Mozambique in its fight The OIG systematically audited recipients and identi- against the three diseases. (Please note that the discrep- fied US$118 million in losses as of 19 September 2013 ancy between values of signed, committed, and [23]. It is important to note that these losses are only disbursed is due to active grants.) The average portfolio 0.5% of the US$22.7 billion that the Global Fund had is US$466 million making Mozambique the 12th highest disbursed worldwide at the time [24]. Overall, the Global recipient of Global Fund support [3]. Fund has a particularly high level of financial account- Of Mozambique’s 17 grants, 12 have been awarded to ability, compared with other global health agencies, and the Ministry of Health, representing 86% of funds is diligent in its response to these relatively small abuses. disbursed to Mozambique. From 2004 and 2008 the Global Fund disbursed US$135.8 m into a health finan- cing basket, known as PROSAUDE [27]. PROSAUDE The new funding model was part of the state budget and was the common fund Reforms resulted in what became known as the New for development assistance in health (the basket fund) of Funding Model (NFM). It has five key characteristics: the Mozambique sector-wide approach to health sector flexible timeline, simplified grant application processes, funding. shorter approval processes, enhanced engagement of all In early grants, scorecards issued at the end of Phase I partners prior to grant submission, and improved pre- often reported “weak financial management practices dictability of funding [25]. In short, the reform focuses and capabilities within the MOH resulting in weak fi- on processes, not structure or paradigm. nancial accountability for resources used” along with dif- Initially the Global Fund application process was in ficulties tracking funds in PROSAUDE [28–32]. In 2011, distinct rounds announced by a call for proposals ap- in response to calls for increased accountability, the OIG proximately three months before a submission deadline. began an audit of Global Fund grants to Mozambique’s In the NFM, funding cycles are flexible and countries Ministry of Health for years 2008, 2009, and 2010 [27]. can submit a so-called concept note any time during Five months into the audit they concluded a total of windows. This allows countries to align the grant US$3,318,395 was inadequately accounted for. The timeline with national fiscal years and strategies. OIG recommended that the Ministry of Health repay Countries are eligible to apply for a pre-assigned the PROSAUDE. Overall, they concluded that there amount per disease, called “the envelope”. Envelopes were not “adequate controls … in place to manage Warren et al. Globalization and Health (2017) 13:89 Page 4 of 14 Fig. 1 Comparison of the Rounds-based funding process and the New Funding Model [26] the key risks impacting the Global Fund supported and the NGO coordinating body (Table 1). Interviews programs” [27]. were held in the offices of key informants in Switzerland This study was conducted to understand how the and Maputo, Mozambique. Interviews lasted approxi- Global Fund was experienced by key stakeholders in mately one hour but ranged from 45 min to three hours. Maputo, Mozambique and how recent reforms were ex- Investigators contacted prospective interviewees via perienced by key stakeholders in Mozambique as well as email. We obtained email addresses through professional by Global Fund stakeholders in Geneva, Switzerland. In late 2013 members of the research team conducted in- Table 1 Interviewees by representation terviews with 38 representatives from these two groups. Representation Number of Nomenclature in interviewees paper Global Fund Board 5 GFBoard Methods Global Fund Secretariat 5 GFSecretariat Primary data collection a b Global Fund Country Structure 4 GFCountryStructure Data was collected as part of a larger study on the influ- Academia 1 Academia ence of emerging donors in health development [33]. For the purpose of the larger study “emerging donors” Consultant Firm 2 Consultant includes public-private partnerships, philanthropic foun- b Non-governmental organization 3 NGO dations, corporate social responsibility programmes, Multilateral Agency 6 Multilateral Brazil, Russia, India, China, South Africa (the BRICS) OECD Partner 10 OECDPartner [34], and other emerging economies. The investigators Coordination Body 2 Coordination conducted 37 face-to-face and one phone-based semi- Total 38 structured in-depth interviews with stakeholders in Maputo, Mozambique and members of the Global Fund Location of interviews: 11 of the GF and 4 of the OECD and Multilateral Agency interviews were conducted in Geneva. The remaining 23 interviews Board and Secretariat in Switzerland. In-country stake- were conducted in Mozambique holders were representatives from Global Fund country includes Local Fund Agents, Country Coordinating Mechanism, Principal Recipients, and Sub-Recipients; members of the CCM may be a representative structures (e.g. Principle Recipient), the Ministry of of a multilateral agency or OECD Partner (Organization for Economic Cooperation Health, health or development attachés of partner em- and Development) bassies in-country, selected UN agencies, consultants, refers to interviewees in chronological order Warren et al. Globalization and Health (2017) 13:89 Page 5 of 14 contacts and official websites. Emails contained a brief engagement. The interview notes were indexed using the description of the research team, overall research framework and included sub-themes as determined by questions and objectives, and methods. Respondents the initial analytic coding [35]. suggested additional interviewee(s) who were then con- To maintain respondents’ anonymity, each interviewee tacted directly by the research team. was given a label with the following nomenclature: two Interviewers used a semi-structured interview guide letter country code, professional affiliation, and number (Additional file 1). Discussions included questions about (based on chronological order of interviews of people interviewees’ perspectives on overall changes in develop- with same professional affiliation). For example, “OECD- ment assistance for health and resulting influences at Partner2” for the second OECD Partner interviewed. country-level. Interviewees were also asked to share their opinions about who they perceived to be the most influ- ential private sources of finance including the Global Results Fund. Many of interviewers’ questions were in the Each country in the larger four-country study on emer- context of the Global Fund as an international non- ging donors for health had a different experience and governmental organization as opposed to an intergov- relationship with the Global Fund, but the general tone ernmental organization or a purely bilateral donor. We of response in Mozambique was that of a question- does asked open-ended questions about Global Fund engage- the current approach of the Global Fund fit with ment with the government and other donors. Inter- country-level needs? Most interviewees were active be- viewers allowed respondents to lead discussion for the fore, during, and after a protracted audit and were left most part and followed up with more detailed questions with concerns about the future of the Global Fund in for clarification. Interviewers also asked questions based Mozambique as it undergoes its first phase of reform. on insights provided in earlier interviews. Global Fund wants to follow only its own rules, and here The 15 interviews conducted in Switzerland followed a it is not working (Multilateral3). Perhaps the Global similar structure to those in Mozambique. Five of these Fund’s inflexibility to recipient needs is because it tends interviews were conducted much later, in mid-2015, to be obsessed with financial technicalities (Multilat- after an initial content analysis, and focused on the eral2). Respondents in both Mozambique and Global Fund and the New Funding Model, specifically Switzerland voiced concerns about the combination of (Academic1, NGO1, GFCountryStructure1, GFBoard4 weak country presence/oversight/guidance with strin- and 5, and GFSecretariat5). gent and cumbersome requirements for monitoring and In Mozambique 23 interviews were conducted. The evaluation (M&E) linked to performance-based financing discussions were primarily in English with periodic (Table 2). They felt this combination forces buttressing clarifications in Portuguese as one investigator speaks by partners. Respondents in Geneva also expressed con- Portuguese fluently. In Switzerland, 11 interviews were cern that perceived weaknesses of partners add risk in conducted with 13 interviewees. All discussions were in this paradigm. English. One phone-based interview was conducted in There appears to be a strong association in the minds English, and a second member of the in-country NGO of respondents in Mozambique between performance- coordination body provided input via email in response based funding, financial tracking, and the audit. This to later follow-up. results in concerns about the Global Fund’s overall Key informants in Mozambique received follow-up approach. There have been a lot of discussions about questions nine months after the initial interview. Of the Global Fund’s inflexibility and unrealistic demands of a 24 interviewees, eleven responded and two referred the developing country. ‘You are asking for oranges, but we investigators to new respondents who provided insights. only have bananas’ (OECDPartner1). Some respondents were more hopeful that distance from the audit will Analysis change the relationship with the Global Fund. The Glo- The corresponding author combined interviewers’ notes bal Fund has a horrendous story with performance-based into one Microsoft Word document per interviewee and financing. There have been improvements in the past two organized the material into fundamental themes- type of years (OECDPartner2). Both of these quotes illustrate a donor, aid management, health system, country context, disconnect between the perception of Performance- etc. The corresponding author uploaded interview notes based finance (PBF) at headquarter-level and at the into MAXQDA 11 (UdoKuckartz; Berlin, Germany) and country-level. In Geneva they believe this approach will read each at least three times. Each successive reading ultimately help countries identify obstacles to meeting was accompanied by descriptive, analytic, and thematic national goals and incentivize problem-solving. In coding, respectively, to assemble discussion points on Mozambique this approach feels based on implausible the Global Fund paradigm and country-level expectations and a resulting frustration. Warren et al. Globalization and Health (2017) 13:89 Page 6 of 14 Table 2 Summary of country-level perceptions of the Global Fund’s paradigm Aspect of paradigm Perceived country-level result Respondent(s) Performance-based financing � Recipients’ focus on disbursement rather than results OECDPartner10 � Burdensome administrative requirements GFCountryStructure4 � Duplication of reporting efforts from the Multilateral3 ground all the way to central level Emphasis on financial technicalities � Staff with financial rather than development GFBoard4 background who lack country experience Lack of country office � Other partners doing monitoring for the Global Fund OECDPartner2 � Global Fund is not engaged in country-level coordination Coordination1, OECDPartner3 � Forces partners to coordinate among themselves more Multilateral2 � Frequent deadlines and time stress GFSecretariat5 � Over-worked staff, communication challenges, out-of-touch GFSecretariat5 with realities on the ground � Dependent on expertise and interest GFBoard4, GFCountryStructure1, GF of single person (Fund Portfolio Manager) Secretariat5 Partnerships � Reliance on external consultants to develop proposals Multilateral2 � Early identification of gaps and provision of additional OECDPartner6 support � Undefined roles and concerns about accountability GFBoard2, GFCountryStructure4 � Potential for agenda alignment with single GFBoard1, GFCountryStructure2, GFSecretariat5, partner and less coordinated/multilateral approach OECDPartners2, 3, and 10 Interviewees in Mozambique and Geneva agreed there The technical support provided by partners is an inte- are problems associated with the current paradigm of gral component of the principle recipients’ success and, country oversight. The Global Fund has weak country therefore, the Global Fund’s success. The amount of sup- presence. Much more oversight is required; they must do port buttressing the Global Fund’s activities depends on more than disburse funds (OECDPartner10). Something the country (GFCountryStructure1). In Mozambique, that is missing in the Global Fund’s current approach is [w]e still have to rely on external consultants to develop close contact with the realities on the ground. There is our proposals (Multilateral2). Discussions in Geneva re- also a high level of internal movement that affects con- vealed that there is tension among stakeholders regard- tinuity (GFBoard4). GFBoard4 commented, [e]mployees ing reliance on technical partners and how these need a strong financial background rather than focusing relationships are financed. On the one hand, if the on a background in development or field experience. This Global Fund is not going to develop its own technical was linked to the discussion about the Global Fund’s capacity, it has to be able to rely on useful, helpful, ac- quickness to remind that “we are a funder, not a devel- tionable guidance from the partners and I think that has opment agency.” This contributes to the perception the been a real problem (GFBoard2). Furthermore, Multilateral2 voiced, Global Fund tends to be obsessed with financial technicalities. The big problem has been basically from the creation The Global Fund reportedly uses effective coordin- of the Fund that technical partners are very important; ation as a criterion for grant approval. The success of the they are the ones who are present on the ground … And application for Phase II of Round 9’s grants for HIV/ many of the countries depend on the technical assistance AIDS and malaria was contingent upon the coordination and the guidance from these technical partners. … It among partners. So, effective coordination among part- works already quite well in some countries and less well ners is recognized as a potential weakness in in others. And the challenge is to get more consistent, let’s Mozambique (Coordination1). However, as there is no say, quality of technical assistance provided by these country presence, the Global Fund itself doesn’t partici- partners (GFSecretariat1). pate in coordination bodies. Engagement with the Health Partners Group would greatly enhance the Glo- Discussion bal Fund’s understanding of country-level activities as History of the Global Fund in Mozambique this coordination body is a clearing house of what each Mozambique first received Global Fund support in partner is doing (OECDPartner3). Round 2 (year 2004) for all three diseases. The Global Warren et al. Globalization and Health (2017) 13:89 Page 7 of 14 Fund signed Mozambique’sfirst Memorandum of The Global Fund paradigm Understanding (MoU) for the sector-wide approach, The Global Fund highly values recipient ownership in the PROSAUDE basket fund. It channelled resources program development, implementation, and evaluation through the basket until the audit of Round 7. Due [40]. The PR leads grant application, administers funds, to problems with reporting and tracing expenditure, develops their targets for performance-based funding, the Global Fund paused funding for Round 8 (year and tracks results [41]. Due to this emphasis on country 2008) [36–39]. Meanwhile the second PROSAUDE ownership, the Global Fund operates without country MoU was released; the Global Fund did not sign. offices [42]. Communication with the Global Fund is en- The Round 8 grant expired while awaiting results of tirely dependent on country teams. Often the PR seeks the OIG’s Round 7 audit. Continued support during technical assistance, particularly for grant application the audit would have required a parallel system for and evaluating performance [43]. Additionally recipients operation. Interviewees gave different accounts of the are typically supported, to some degree, by development audit. Those who work closely with the Global Fund partners on the ground [44]. Bilateral agencies working described it very matter-of-factly. To paraphrase: It in the country provide support, some more than others, was initially claimed that US$14 million was un- because they also have vested interest in Global Fund’s accounted for, but after one year, the audit deemed success as they are donors to the Global Fund [45]. US$1 million missing. This is not surprising given the The Global Fund is a financier, rather than an imple- nature of pooled funding. Eventually the government menting/development agency. Along with other global repaid the US$1 million (OECDPartner1). But one health initiatives created in the early 2000s, it was de- interviewee from a bilateral agency was more cutting signed to overcome market and public failures in inter- in response, national public health, as well as disperse the power of the UN and its agencies [46–48]. It was meant to offer In standard auditing protocol, the organization would streamlined, less bureaucratic, processes. Respondents in be given three months to provide proper evidence for Mozambique suggested that the Global Fund currently spending. The Global Fund gave three months, three functions somewhere between its predecessors and the times. … This is not good practice. The Global Fund hid vision of its creators. behind its procedures. They did not grant access to their draft reports even though they audited bilateral funding The Global Fund has straddled between a managerial by nature of auditing pooled funding. This is not a and a bureaucratic model in Mozambique. They try to healthy approach. They are not improving health or a apply performance-based financing, but their grant man- health sector when covering up results this way agement processes have been highly bureaucratic. They (OECDPartner10). function as a bureaucracy, but they’d like to have performance-based targets (OECDPartner1). Three years after the audit, the Round 8 Health System Strengthening grant was re-constituted in June The cost of the bureaucracy extends beyond cumber- 2012. The Ministry of Health is the principle recipi- some administrative processes … [s]o much money spent ent, and the grant focuses on risk mitigation and on managing and getting through the bureaucratic re- reporting as per the OIG’s report. Despite the Global quirements of the Global Fund (OECDPartner1). Fund reforms in application processes, [the grant pro- Despite respondents’ concerns, they were hopeful posal] went through the old bureaucratic processes about prospective changes with the New Funding Model, (OECDPartner1). and more importantly about the capacity of the Global In Mozambique the audit, requirements for financial Fund to reform at all. The Global Fund’s New Funding management, and performance-based approach, have in- Model addresses inefficiency concerns, and the recent spired questions about Global Fund’s paradigm given the changes in the Global Fund have shown how contexts in which it works. One quote in particular international organizations are capable of re-inventing encapsulates many of the concerns addressed piece-meal themselves (GFCountryStructure2). in other interviews. The Global Fund’s reform is unique for a large-scale organization [49, 50], and respondents seemed to be The Global Fund has two choices: either continue to providing constructive criticism with the hope that feed- not have people on the ground or relax their require- back would result in further reform of the Global Fund. ments for monitoring and evaluation. As it stands there is no one on the ground, they maintain their high expec- Performance-based funding tations, and have other partners doing their monitoring Results-based financing is an attempt to link financial for them (OECDPartner2). input to health-related outcomes. Development partners Warren et al. Globalization and Health (2017) 13:89 Page 8 of 14 compare the results of the funded project or program to of paperwork to fill out … All data that is not aggregated pre-determined targets for a set of indicators. Although in the routine national health information system must be this approach is not new, there is a broader range of ac- gathered in the programme (GFCountryStructure4). tors using a wider range of results-based models. If im- Multilateral3 shared that Mozambique has performed well plemented properly, results-based finance can: align and accomplished targets despite the obstacles posed by donor and recipient objectives, improve data reliability, Global Fund requirements. give recipients a stake in the outcome of their efforts, Mozambique does not necessarily have the financial and give recipients greater discretion and authority to management capacity required to satisfy Global Fund carry out their tasks [51]. On the other hand there are demands, and this directly affects return-on-investment concerns about the effectiveness of these tools for health measurements. Additionally, addressing the obstacles development [52] and the feasibility of measuring out- identified in the performance evaluation would require comes of complex, system-level interventions [53, 54]. systems support. To date, studies have focused on approaches that focus on paying for the results achieved by individuals or insti- They give more money than such a weak system can tutions (for example, health facilities or central medical properly absorb. So overall they might be doing more stores). There has only been one study on results-based harm than good. Giving such a large sum of money with- approaches to grant management [37]. out the proper checks and balances leads to corruption Performance-based finance (PBF) is one of the guiding and growing inequality (OECDPartner10). principles of the Global Fund; continued support for re- cipients depends on proven results. Their strategy to Mozambique is not alone in this. Low absorption “actively manage grants based on impact, value for capacity has been blamed for the failure of many devel- money and risk” includes increased emphasis on impact opment assistance projects in African countries. Donor of funding, investment in data systems, requirement of agencies complain that insufficient physical infrastruc- increased financial management transparency, coordin- ture and technical expertise at the local level generate ation with recipients and other donors, and avoidance of high transaction costs and, thus, inefficiency in project duplicated or inconsistent demands on recipients [55]. implementation. Distribution and institutional channels GFSecretariat2 shared that the organization uses a in Mozambique are weak and thus the US government more progressive model of PBF than a strictly results- takes a hegemonic approach (GFCountryStructure2). based approach. Currently the approach centers upon The managerial needs of aid administration and imple- progress and improved performance of national pro- mentation are often overlooked. This leads, among grams. They focus on country ownership of results and others, to slow delivery of assistance and reporting prob- corrective actions. The Global Fund wants to understand lems [56–59]. why a country is not performing, not just where the Based on the interviews in Mozambique, it is difficult money is going. Part of this decision-making is to get to know if the intention of the Global Fund’s PBF has countries themselves to do their own performance re- been communicated on the ground, or if it’s been over- views. So part of it is not just the mechanical rating, it’s shadowed by the administrative burden placed on the that they actually do review their results against their principle recipient. A Geneva-based interviewee made a targets, and they explain the deviations and they come to comment that implies, to date, headquarters has recog- an overall rating (GFSecretariat2). nized the need for change. [We need to] push down the While this approach is arguably more holistic, it has performance-based funding so that it’s not just done in a been reasoned that the subjective elements of their evalu- committee room in Geneva, but there are these program ation decrease incentives to improve performance [37]. reviews that are done within countries, … we need to in- This conclusion was supported by a development partner vest much more that there’s a process in-country, and in Mozambique. The recipients’ criterion for success is dis- performance-based at the country level (GFSecretariat2). bursement rather than results (OECDPartner10). Until countries take full ownership of this process and The Global Fund approach was described as a stream- are empowered by the intended purpose of lined skeleton which countries built upon to create their performance-based financing, PBF will likely continue to own performance evaluation. …we had several hundred be perceived as an administrative burden and identified indicators and we’ve reduced it down to a top set of 10, as a siloed donor demand. which are highly weighted, but then a country can use fur- ther indicators. They have to set targets, and then it’s really Country oversight how many of those targets are reached (GFSecretariat2). The Global Fund does not have country offices. Instead But concerns at the country-level focus on burdens placed they rely on country teams that are based in Geneva, on data collection systems. There is an enormous amount travel to the country, and are led by a Fund Portfolio Warren et al. Globalization and Health (2017) 13:89 Page 9 of 14 Manager with support from 3rd party Local Fund In-country coordination Agents at country level. The team is comprised of Coordination among donors is central to the programme officers, and legal, procurement, finance, harmonization pillar of the Paris Declaration as one of and M&E staff [60]. Team members are responsible for three principles to avoid duplication [61]. Mozambique multiple countries. Previously country teams typically has a Health Partners Group that meets monthly and visited Mozambique once annually, but with the changes brings together all health sector supporters, including under the New Funding Model, teams visit countries representatives of civil society. In 2008 Mozambique multiple times per year (Multilateral4; OECDPartner2). signed an International Health Partnership (IHP+) com- This increase in frequency has yielded mixed reviews. pact [62]. It is a commitment among partners to Many respondents saw it as an improvement because harmonize and align their support with nationally de- the country teams are becoming more familiar with the fined priorities (to the extent that their procedures realities on the ground and are available for guidance. allow). A Global Fund Board Member identified IHP+ as One respondent contradicted this feedback. Countries the most important opening that we have right now also complain that country teams come too often. There (GFBoard3) for increased coordination and collaboration is not enough time to make progress between visits, they with other development partners. are constantly working for the next visit, and this in- Many more coordinating bodies have been created in creases the time stress (GFSecretariat5). Overall, the Mozambique as a result of absorption challenges. These major concerns voiced by respondents were that country include the G19 (a group of bilateral donors who pro- teams are over-worked and are therefore sometimes un- vide sector-wide support and coordinate among them- successful as the channel for communication, too much selves), the National AIDS Council (Conselho Nacional depends on an individual (the Fund Portfolio Manager), Contra o SIDA), NAIMA+ (NGOs coordinating body), and the country teams are out of touch with the realities etc. As one donor representative put it, [the coordinat- on the ground. ing bodies] in Mozambique they are a nickel a dozen! Aside from technical support for proposal develop- This is due to a very weak civil society. If you get an or- ment and grant implementation, country teams act as ganogram of the Ministry of Health, you will see so many the primary channel of communication with Global directors and sub-directors, but not many technicians Fund headquarters. The Global Fund does not put things (GFCountryStructure2). on their website to communicate widely with stake- This has led to conventional donors and local officials holders, including at the country level. They rely on Fund spending exorbitant time on coordination, rather than Portfolio Managers and people on the country team on implementation issues. Coordination among different (NGO1). Interviewees in-country and in Geneva ‘market players’ involves notably high transaction costs expressed concern about the reliance on country teams. [58]. Yet, integration into a single organization with uni- The availability of expertise within the team is country- fied goals involves either high bureaucracy costs [63] or dependent. … Personnel are over-worked and over- requires very strong leadership [64]. extended and as a result it is not uncommon for them to All respondents who represent the Global Fund agreed take extended leave. This has caused detrimental gaps in that coordination at the country-level is vital for success- communication (GFCountryStructure1). The Global ful implementation. A member of the Secretariat com- Fund has recognized some of the issues associated with mented on coordination as if it is integral to the nature the burden placed on country teams and has begun to of the Global Fund’s engagement. We are a contribution bring in technical expertise to help (GFSecretariat5). model and impact only really occurs when you’ve got One Board Member emphasized the importance of in- other donors in the national program also contributing creasing coordination with other development partners (GFSecretariat2). The picture painted by most country- in-country to address shortcomings of the country team. level respondents was very different. Only one partici- The Global Fund is currently doing stakeholder mapping pant suggested that s/he was satisfied with the Global at the country level so that the network of partners is Fund’s influence on country-level coordination. Pro- clear. For now, at least, country teams are staffed with grammatically they brought a new approach. They forced very bright people that regularly visit the country partners to coordinate more (Multilateral2). Decision- (GFBoard5). GFBoard2 suggested that some of these makers at the Global Fund did voice the need for concerns could be addressed with clearer expectations improvement. Few specifically mentioned country-level for a Fund Portfolio Manager and more effective coord- coordinating bodies, but they recognized that the only ination among constituents. Essentially, there needs to way to avoid duplication is through coordinating with be changes in the hiring of Fund Portfolio Managers other actors. There’s definitely more to be done. Fortu- combined with diffused powers in oversight of grant nately, it’s moving in the right direction. It’s crazy to think implementation. you can do appropriate due diligence of a proposal for Warren et al. Globalization and Health (2017) 13:89 Page 10 of 14 funding to the Global Fund if you don’t understand what the most involved of all the Global Fund donors both fi- other people are already funding (GFBoard2). Overall nancially but also in terms of coordination at the respondents expressed frustration about the Global project-level. All of Global Fund’s activities on the ground Fund’s lack of coordination; this was a near-universal in Mozambique are coordinated with PEPFAR and the theme at the country-level. This was mirrored by President’s Malaria Initiative [PMI] (OECDPartner6). GFCountryStructure1’s reflection that the main criticism during the rounds-based model- the lack of coordination In Mozambique the US government even has a Global with in-country partners. Fund Liaison on the payroll. This position was created The Global Fund’s challenges with coordination are not to increase coordination of Global Fund with PEPFAR unique among implementing agencies in any field of de- and [PMI] The position is pay-rolled by USAID, PEPFAR, velopment nor is Mozambique’s ineffective coordination or US Centers for Disease Control [CDC] depending on unique among recipient countries (manuscript in prepar- the country (OECDPartner1). Respondents expressed ation). Rather these challenges are symptomatic of a confidence in the liaison and saw the position as the best widespread trend in development assistance in most window into Global Fund support. One interviewee con- sectors [65, 66]. trasted it with the intended mechanism of coordination. Partnerships The Global Fund liaison is more effective than the The two largest donors to the Global Fund, the United Country Coordinating Mechanism because the members States and France, both contribute 5 % of their pledges of the [CCM] are not actually paid; if the [CCM] were to to technical assistance (TA) [3]. The 5 % is channelled become institutionalized, it would result in a parallel through their bilateral development agencies or their re- system (Multilateral5). spective technical bodies founded to support Global Fund principle recipients- Grant Management Solutions This degree of support from the US government has and Initiative 5% [67, 68]. Information, personnel, been invaluable in Mozambique. They are able to identify finance, equipment, and supplies are all forms of TA for gaps early on and provide additional support as needed. which applicants are eligible [69]. The latest published The National HIV/AIDS Acceleration Plan [financed by list of providers of technical assistance was in 2004 [69]. the Global Fund] … is projected to have a massive gap in At the time there were 170 Global Fund-related tech- commodities procurement, which the US government will nical assistance providers (135 organizations and 35 ultimately need to fill (OECDPartner6). But interviewees technically-qualified individuals). At the time of writing, also shared concerns of when the agenda of the US gov- the Global Fund website listed six organizations that ernment and the other donors do not align. offer TA. Aside from requests for technical cooperation on community, rights, and gender issues, the Global US Congress sets specific targets … that make it im- Fund encourages direct contact with TA providers [43]. perative for US development activities to follow their own The consultants hired to advise countries on strategies goals. Otherwise Congress will cut funding. … US funding for their concept note development are paid by the part- has far more constraints and accountability rules, so that ners. … There is a lot of money flowing for Global Fund little of it goes directly to the Mozambican government. engagement that is not accounted for. … These activities PEPFAR has a more efficient implementation machine, are coordinated at the country level, at the Development but –indeed—perhaps the long-term coordination suffers Partners Group (GFBoard4). (GFCountryStructure2). Interviews in Mozambique revealed that partners do more than provide TA, they also step in to fill gaps. This response was independently supported by other When there are delays / gaps with the Global Fund, interviewees (OECDPartners 2 and 3) who touched upon other donors step in for support. The other donors’ re- donor relations in Mozambique and the disagreement sponses are not formally decided or premeditated among the G19 about expectations to hold. (OECDPartner6). The US government is the largest donor in the health sector; they provide more develop- US government recognizes that Mozambique has weak ment assistance for health than all other donors com- systems and provides support for the system so as not to bined (GFCountryStructure2). They often fill gaps in set them up to fail but expects them to be a genuine part- Global Fund support due to the fact that they are both ner and makes changes based on lessons learned. The Mozambique’s and the Global Fund’s largest investor. Global Fund expects the Ministry of Health to apply for funds and then take a “do-it-yourself” approach to The US government is very invested in Mozambique’s systems strengthening, but this fails because they need success with the Global Fund … The US government is support (OECDPartner2). Warren et al. Globalization and Health (2017) 13:89 Page 11 of 14 Some partners question the boundary between the US example, the WHO, to address stringent performance- government and the Global Fund. In Mozambique criti- based funding reporting requirements. Additionally they cizing the Global Fund is criticizing US government as- require buttressing by bilateral donors who provide fi- sistance (OECDPartner10). Based on discussions with nance to the Global Fund and the countries in which it Board Members in Geneva about partners providing operates, for example, the US government (Table 2). TA on the ground, this concern extends up to the highest levels and is perhaps not unique to Mozambique. Ability to reform A member of the Secretariat reinforced the prospect Overall, there were mixed reviews on what the New that there is enmeshment of Global Fund and US Funding Model has, or will, actually change on the government agendas at the highest level. When asked if ground, but multiple interviewees referred to the Global Global Fund’s donors are coordinating to maximize their Fund’s ability to reform as one of the defining character- contributions the interviewee only discussed coordin- istics of the organization. It was a prominent, recurring ation with the US government (USG). The Global Fund theme in interviews. has formed a partnership with PEPFAR to avoid duplica- tion. … The USG focuses on service delivery and “Global Fund has proved in 10 years to have the abil- community-level interventions, and the Global Fund ity to renew itself” (Multilateral4). works at the national level (GFSecretariat5). It is unclear from GFSecretariat5’s response at what level the US gov- “The Global Fund’s New Funding Model addresses ernment is supposed to share knowledge, and with inefficiency concerns, and the recent changes in the whom exactly. Global Fund have shown how international The degree of external support required for the Global organizations are capable of re-inventing themselves” Fund’s success has raised a debate on accountability. To (GFCountryStructure2). whom are the providers of TA held accountable?… the most difficult part of the Global Fund model is the part- “Overall, the Global Fund is learning from its mistakes. nership model. It depends on the support of partners and … the Global Fund, completed its reformation in one yet it doesn’t have any say over the partners. … I think year. It is a ‘learning organization’; it is navigating we need to figure out what that relationship should be through a field of opposing forces, and is highly commit- (GFBoard2). ted to its mission” (GFBoard4). In Mozambique this blurry line extends to the Minis- try of Health. The US government pays for the Global Although many of the reforms have not yet addressed Fund Unit in the Ministry of Health (OECDPartner6). concerns about the Global Fund’s overall model, inter- It’s in the Department of Planning and Coordination and viewees seemed to be looking beyond this initial trans- is responsible for coordinating Global Fund projects. In formation. They clarified that although their responses terms of coordination, the US government is the only bi- were critical of the Global Fund, they admire the Fund’s lateral donor that [the Global Fund Unit] has contact work (GFBoard4 and GFBoard5). This sentiment is with (GFCountryStructure4). linked to the organization’s ability to reform- respon- A new channel was created to manage Global Fund dents can use opportunities such as interviews to share money in 2010/11 in response to the Global Fund’s lessons learned about perceived strengths and weak- withdrawal from the health financing basket. Rather nesses of the Global Fund with the hope that they are than going directly from the Ministry of Finance to included in the next wave of changes. the Ministry of Health, money goes through the Global Fund Unit. The combination of burdensome “I think there is commitment from the Secretariat as requirements and weak oversight has resulted in the well certainly from our constituency and others to im- need for an entire unit within the Ministry of Health. prove the Funding Model. As Mark Dybul is the first to Mozambique is an example of a country undergoing say, ‘we haven’t got it all right’, this will be an iterative internal reform of reporting systems to adapt to Glo- process to continuously improve how the new funding bal Fund requirements (GFBoard4). The fact that it is model works” (GFBoard2). paid for by the US government means that it is ac- countable to the US government and not the Mozam- As one respondent pointed out, the continued success bican government. of the Global Fund in Mozambique is important because The Global Fund’s lack of country presence results in the Global Fund is a means of getting around the govern- inadequate coordination with in-country partners. It also ment; the government does not necessarily reflect societal necessitates support from technical partners, for demands (OECDPartner3). Warren et al. Globalization and Health (2017) 13:89 Page 12 of 14 Conclusions Além disso, os tomadores de decisão em Genebra recon- In Mozambique the Global Fund is viewed as an institu- hecem que a coordenação local é necessária para a tion that is uniquely capable of reform. Despite the implementação bem-sucedida; outros parceiros locais changes with application processes that are associated apreciariam o envolvimento do Fundo Global. Até agora, with the New Funding Model, respondents in both não há requisitos institucionais para a coordenação for- Geneva and Maputo firmly believed that challenges re- malizada e, no momento das entrevistas, o Fundo Global main in the inherent structure and paradigm of the não tinha uma representação consistente em nenhum Global Fund. The lack of a country office has many dos grupos de coordenação no país. negative downstream effects including reliance on part- Embora a decisão do Fundo Global de não ter escritórios ners in-country. Due to weak managerial and absorptive locais possa ser justificada, as dificuldades locais sugerem capacity, more oversight is required than is afforded by que o Fundo Global deve adoptar uma abordagem mais country team visits. In-country partners provide much consciente, adaptando os mecanismos de subvenção e os needed support for Global Fund recipients, but roles, re- procedimentos de monitoramento às realidades locais. sponsibilities, and accountability must be clearly defined Deve-se estabelecer regras que sejam flexiveis e simultânea- for a successful long-term partnership paradigm. Fur- mente respeitem as demandas da sede central. Isso desloca thermore, decision-makers in Geneva recognize in- para a sede central a responsabilidade de avaliar se os rela- country coordination as vital to successful implementa- tórios dos países cumprem as exigências. O Fundo Global tion, and other actors in-country would welcome Global poderia associar essas mudanças com uma política mais Fund engagement. To date, there are no institutional re- formalizada de coordenação no país. quirements for formalized coordination, and at the time of the interviews the Global Fund has no consistent Take-home messages representation in any in-country coordination groups The lack of a country office has many negative despite its focus on performance-based finance. downstream effects including over-reliance on part- Although the Global Fund’s decision against having ners in-country. local offices in order to encourage local ownership may Although partnerships provide much needed be justified, the various downstream difficulties suggest support for Global Fund recipients, roles, that the Global Fund should adopt a more conscientious responsibilities, and accountability must be clearly approach by adapting grant implementation and moni- defined for a successful long-term partnership. toring procedures to the specific local realities. It should The Global Fund emphasizes coordination at the establish procedures that allow room for flexibility while higher levels of the organization, but country teams’ remaining harmonized with headquarter demands. This engagement with other actors in-country is shifts the onus to headquarters to assess whether what a dependent on the Fund Portfolio Manager. country reports meets the requirement. The Global The Global Fund’s ability to reform is seen as Fund could couple these changes with a policy for for- unique, and respondents see its approach as malized coordination in-country. continually evolving. Additional Portuguese conclusions Mensagens principais Em Moçambique o Fundo Global é visto como uma  A ausência de um escritório no pais tem causado instituição que é particularmente capaz de se reformar. muitos efeitos negativos, incluindo a dependência do Apesar das mudanças nos processos de solicitação asso- Fundo em parceiros locais. ciados como o Novo Modelo de Financiamento, os con-  As parcerias acomodam o apoio necessário aos sultados em Genebra e Maputo acreditam firmemente beneficiários do Fundo Global, mas as tarefas, as que ainda permanecem desafios na estrutura inerente e responsabilidades e as prestações de contas devem no paradigma do Fundo Global. A falta de escritórios ser definidas mais claramente para ter uma parceria locais tem muitos efeitos negativos, causando dependên- bem-sucedida a longo prazo. cia em parceiros nacionais. Devido à capacidade fraca de  Fundo Global enfatiza coordenação nos seus níveis gerenciamento e de absorção é necessária mais supervi- mais altos, mas o nível de envolvimento das equipes são da que é possível atualmente nas visitas do gerente dentro de Moçambique com parceiros dentro do de carteira em Genebra. Parceiros em Moçambique for- país depende do gerente de carteira do Fundo. necem apoio aos beneficiários do Fundo, mas as difer-  A capacidade de reforma do Fundo Global pode ser entes tarefas, responsabilidades e prestações de contas vista como uma oportunidade única, e os entrevistados precisam ser definidas mais claramente para chegar a consideram sua abordagem como uma evolução um paradigma de parceria bem-sucedido a longo prazo. continua. Warren et al. Globalization and Health (2017) 13:89 Page 13 of 14 Endnotes Received: 20 February 2017 Accepted: 25 October 2017 These include the next eleven emerging economies, N-11 (Bangladesh, Egypt, Indonesia, Iran, Mexico, Nigeria, Pakistan, the Philippines, Turkey, South Korea and Vietnam). References 1. Sherry J, et al. The Five-Year Evaluation of the Global Fund to Fight AIDS, Jakovljevic M, et al. BRICS VS. N-11. In: Health Economics Tuberculosis, and Malaria: Synthesis of Study Areas 1, 2, and 3. 2009, macro and Policy Challenges in Global Emerging Markets. Jakovlje- international. In: . MD; USA: Calverton. vic M, editor. New York: Nova Science Publishers, Inc.; 2. Biesma R, et al. The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy Plan. 2016: 1–18. ISBN 978–1–63,484-720-9 (eBook). 2009;24(4):239–52. 3. The Global Fund. Pledges and Contributions. 2016; Available from: http://www. Additional file theglobalfund.org/documents/core/financial/Core_PledgesContributions_List_en/. 4. The Global Fund. Financials. How We Work 2016 [cited 2015 26 October]; Available from: http://theglobalfund.org/en/financials. Additional file 1: Semi-structured interview guide. (DOCX 20 kb) 5. IHME. Viz Hub: Financing Global Health. 2016 [cited 2016 8 November]; Available from: http://vizhub.healthdata.org/fgh/. Abbreviations 6. Clinton C, Sridhar D. WHO pays for cooperation in global health? A CCM: Country Coordinating Mechanism; CDC: US Centers for Disease Control; comparative analysis of WHO, the World Bank, the Global Fund to fight HIV/ HSS: Health systems strengthening; IHP: + International Health Partnership; AIDS, tuberculosis and malaria, and Gavi, the vaccine alliance. Lancet. LFA: Local Fund Agent; M&E: Monitoring and evaluation; MDG: Millennium 2017;390(10091):324–32. Development Goal; MoU: Memorandum of Understanding; NFM: New 7. The Global Fund. Overview. How We Work 2016 [cited 2015 25 October]; Funding Model; NGO: Non-governmental organization; OECD: Organization Available from: http://theglobalfund.org/eng/overview/. for Economic Cooperation and Development; OIG: Office of the Inspector 8. The Global Fund, The Global Fund Governance Handbook. 2014, The Global General; PBF: Performance-based finance; PEPFAR: the US President’s Fund: Geneva, Switzerland. Emergency Plan for AIDS Relief; PMI: the US President’s Malaria Initiative; 9. The Global Fund, Operation Policy Manual. 2016, The Global Fund: Geneva, PR: Principle Recipient; TA: Technical assistance; TRP: Technical Review Panel; Switzerland. USAID: US Agency for International Development 10. The Global Fund. Donors commit US$11.7 billion to the Global Fund for next three years. News & Stories 2010 [cited 2015 26 October]; Available Acknowledgements from: http://www.theglobalfund.org/en/news/2010-10-05_Donors_commit_ The authors would like to thank all participants for their time and interest in USD_11_7_Billion_to_the_Global_Fund_for_next_three_years/. responding to interviews and follow-up. The authors would also like to thank 11. The Global Fund. The Global Fund confirms freeze on cash disbursements Stephen Browne, Prof. Raymond Saner, Lichia Yiu, and Shufang Zhang for their to Zambia Ministry of Health, grants to be transferred to UNDP. News & contributions to this research by conducting interviews through the SNIS project. Stories 2010 [cited 2015 26 October]; Available from: http://www. We would also like to thank Olivia Meira and Giovanna Centeno Barbalho for theglobalfund.org/en/news/2010-06-16_Global_Fund_confirms_freeze_on_ translating the abstract, conclusions, and take-home messages into Portuguese. cash_disbursements_to_Zambia_Ministry_Of_Health_grants_to_be_ transferred_to_UNDP/. Funding 12. The Global Fund. Global Fund suspends grants to Philippines foundation. This work was funded by the Swiss Network for International Studies News & Stories 2009 [cited 2015 26 October]; Available from: http://www. (reference # 3938) and the Swiss Tropical and Public Health Institute. theglobalfund.org/en/news/2009-09-24_Global_Fund_suspends_grants_to_ Philippines_foundation/. 13. The Global Fund. Global Fund suspends grant to the Executive Secretariat Availability of data and materials of the National AIDS Committee in Mauritania. News & Stories 2009 [cited Not applicable. 2015 26 October]; Available from: http://www.theglobalfund.org/en/news/ 2009-09-09_Global_Fund_suspends_grant_to_the_Executive_Secretariat_of_ Authors’ contributions the_National_AIDS_Committee_in_Mauritania/. AW conceived of the content and prepared the manuscript. AW, RC, and 14. The Global Fund - OIG, The Office of the Inspector General Progress Report DdS edited drafts of the manuscript. All authors read and approved the final for March–October 2010 and 2011 Audit Plan and Budget, Office of the manuscript. Inspector General, Editor. 2010, The Global Fund: Geneva, Switzerland. 15. Heilprin, J., Fraud plagues global health fund, in The Guardian. 2011: London, U.K. Ethics approval and consent to participate 16. Rivers B, Corruption by Global Fund Grant Implementers, in Global Fund The Ethikkommission beider Basel EKBB approved the research protocol on Observer 139. Aidspan: Nairobi. Kenya. 2011; 21 Oktober 2013 (# 288/13). 17. The Global Fund. Independent review of the Global Fund will be concluded by September. News & Stories 2011 [cited 2015 26 October]; Available from: Consent for publication http://www.theglobalfund.org/en/news/2011-05-04_Independent_review_ Not applicable. of_the_Global_Fund_will_be_concluded_by_September/. 18. The Global Fund. The Global Fund Board meets to consider 5-year strategy, Competing interests reform agenda. News & Stories 2011 [cited 2015 26 October]; Available DdS is a member of the Global Fund Technical Evaluation Reference Group (TERG). from: http://www.theglobalfund.org/en/news/2011-05-10_The_Global_ Fund_Board_meets_to_consider_5-year_strategy_reform_agenda/. Publisher’sNote 19. The Global Fund, Global Fund Board adopts Panel recommendations calling Springer Nature remains neutral with regard to jurisdictional claims in for urgent reform. 2011. published maps and institutional affiliations. 20. The Global Fund. The Global Fund's Executive Director to step down in March. News & Stories 2012 [cited 2015 26 October]; Available from: http:// Author details www.theglobalfund.org/en/news/2012-01-24_The_Global_Fund_Executive_ Department of Epidemiology and Public Health, Swiss Tropical and Public Director_to_step_down_in_March/. Health Institute, Socinstrasse 57, 4002 Basel, Switzerland. University of Basel, 21. The Global Fund. The Global Fund appoints Gabriel Jaramillo as General Petersplatz 1, 4003 Basel, Switzerland. Franklin University Switzerland, Via Manager: New Position Created to Implement the Organization's Ponte Tresa 29, 6924 Lugano-Sorengo, Switzerland. Graduate Institute of Transformation Plan. News & Stories 2012 [cited 2015 26 October]; Available International and Development Studies, Maison de la Paix, Chemin from: http://www.theglobalfund.org/en/news/2012-01-24_The_Global_ Eugène-Rigot 2, 1202 Geneva, Switzerland. Fund_appoints_Gabriel_Jaramillo_as_General_Manager/. Warren et al. Globalization and Health (2017) 13:89 Page 14 of 14 22. Harvard T.H. Chan School of Public Health. Gabriel Jaramillo, former General 45. van Kerkhoff, L. and N.A. Szlezak, The role of innovative global institutions in Manager of The Global Fund. 2014 [cited 2016 15 September]; Available linking knowledge and action. Proc Natl Acad Sci U S A, 2016. 113(17): p. from: https://www.hsph.harvard.edu/voices/events/jaramillo/. 4603–4608. 23. Garmaise, D., Global Fund Releases Report on Losses and Recoveries, Global 46. Buse K, Walt G. Global public-private partnerships: part I–A new Fund Observer, Editor. 2013, Aidspan: Nairobi, Kenya. development in health? Bull World Health Organ. 2000;78(4):549–61. 47. Greenall M, et al. Reaching vulnerable populations: lessons from the Global 24. The Global Fund. Grant Portfolio. Where We Invest 2016 [cited 2015 25 Fund to Fight AIDS, Tuberculosis and Malaria. Bull World Health Organ. October]; Available from: http://www.theglobalfund.org/en/portfolio/. 2017;95(2):159–61. 25. The Global Fund. Funding Model. How We Work 2016 [cited 2015 26 48. Kunii O, Yassin MA, Wandwalo E. Investing to end epidemics: the role of the October]; Available from: http://www.theglobalfund.org/en/fundingmodel/. Global Fund to control TB by 2030. Trans R Soc Trop Med Hyg. 26. The Global Fund, The Global Fund's New Funding Model, in The Global 2016;110(3):153–4. Fund to Fight AIDS, Tuberculosis and Malaria: Fourth Replenishment (2014- 49. Hanrieder T. The Reform Reformation: International Organizations and the 2016). 2013, the Global Fund: Geneva, Switzerland. Challenge of Change, in Council on. Foreign Affairs. 2016; https://www. 27. The Global Fund - OIG, Audit of Global Fund Grants to the Republic of foreignaffairs.com/articles/2016-04-08/reform-reformation Mozambique, Office of the Inspector General (OIG), Editor. 2012, The Global 50. Kelland, K., The World Health Organization’s critical challenge: healing itself, Fund: Geneva, Switzerland. in Reuters Investigates. 2016: http://www.reuters.com/investigates/special- 28. The Global Fund. MOZ-202-G03-M-00 : Building Capacity to Scale Up Roll report/health-who-future/. Back Malaria in Mozambique. Grant Portfolio 2016 [cited 2015 26 October]; 51. Savedoff WD. Basic economics of results-based financing in health. Bath, Available from: http://theglobalfund.org/en/portfolio/country/grant/?k= Maine: Social Insight; 2010. 8dacfcaf-f44c-474f-af34-3200847b2b54&grant=MOZ-202-G03-M-00. 52. Oxman AD, Fretheim A. Can paying for results help to achieve the 29. The Global Fund. MOZ-202-G04-T-00 : Strengthening and expanding TB millennium development goals? Overview of the effectiveness of results- services in Mozambique. Grant Portfolio 2016 [cited 2015 26 October]; based financing. J Evid Based Med. 2009;2(2):70–83. Available from: http://theglobalfund.org/en/portfolio/country/grant/?k= 53. Meessen B, Soucat A, Sekabaraga C. Performance-based financing: just a 29c2ec6e-85d5-4cad-99a2-d6c942b3ff07&grant=MOZ-202-G04-T-00. donor fad or a catalyst towards comprehensive health-care reform? Bull 30. The Global Fund. MOZ-607-G05-H : Mozambican Initiative to expand World Health Organ. 2011;89(2):153–6. coverage for prevention, care, support and treatment for people affected by 54. de Savigny D, Adam T. Systmes thinking for health systems strengthening. HIV/AIDS. Grant Portfolio 2016 [cited 2015 25 October]; Available from: Geneva, Switzerland: World Health Organization; 2009. http://theglobalfund.org/en/portfolio/country/grant/?k=3c9cdfd9-7517-4b8f- 55. The Global Fund. The Global Fund strategy 2012–2016: investing for impact. a41c-b5da94ab8796&grant=MOZ-607-G05-H. Geneva, Switzerland: The Global Fund to Fight AIDS, Tuberculosis and 31. The Global Fund. MOZ-708-G07-T : Reducing Tuberculosis Morbidity and Malaria; 2012. Mortality in Mozambique by 2012, through strengthening of the National 56. Austin, J.E., Managing in Developing Countries: Strategic Analysis and Tuberculosis Control Program at all levels. Grant Portfolio 2016 [cited 2015 Operating Techniques. 1990, New York, NY: The Free Press: a division of 25 October]; Available from: http://theglobalfund.org/en/portfolio/country/ Macmillan. grant/?k=bc98b2e4-5c3c-4cfc-95d5-b8cf8e8a727b&grant=MOZ-708-G07-T. 57. Easterly W. The tyranny of experts: economists, dictators and the forgotten 32. The Global Fund. MOZ-911-G10-H : Responding to the HIV epidemic in rights of the poor. New York, NY: Basic Books; 2013. Mozambique through effective government - civil society partnerships. 58. Coase RH. The nature of the firm. Economica, New Series. 1937;4(16):386–405. Grant Portfolio 2016 [cited 2015 26 October]; Available from: http:// 59. Simon HA. Administrative behavior: a study of decision-making processes in theglobalfund.org/en/portfolio/country/grant/?k=cc45cd7f-6744-4689-af93- administrative organizations. New York, NY: The MacMillan Company; 1947. d7c108d50a8c&grant=MOZ-911-G10-H. 60. Garmaise, D., New "Country Team Approach" Adopted for Managing Grants, 33. SNIS. Trends and Influence of Private Finance on Global Health Initiatives Global Fund Observer, Editor. 2010, Aidspan: Nairobi, Kenya p 8-9. and Development Goals in Resource-constrained Countries. 2012 [cited 61. OECD, Paris Declaration on Aid Effectiveness. Organization for economic 2016 10 October]; Available from: http://www.snis.ch/project_trends-and- co-operation and development (OECD). Paris: France; 2005. influence-private-finance-global-health-initiatives-and-development-goals. 62. IHP+, Mozambique Compact, Department of Health Systems Governance 34. Jakovljevic MB. BRIC's growing share of Global Health spending and their and Financing, Editor. 2008, International health partnership, World Health diverging pathways. Front Public Health. 2015;3:135. Organization: Geneva, Switzerland. 35. Gale NK, et al. Using the framework method for the analysis of qualitative 63. Williamson OE. Markets and hierarchies: analysis and antitrust implications. data in multi-disciplinary health research. BMC Med Res Methodol. New York, NY: The Free Press; 1975. 2013;13:117. 64. Selznick P. TVA and the grass roots: a study in the sociology of formal 36. Bridge J, et al. The Global Fund to Fight AIDS, Tuberculosis and Malaria's organization. Berkeley and Los Angeles, CA: University of California Press; 1949. investments in harm reduction through the rounds-based funding model 65. Mwisongo A, Nabyonga-Orem J. Global health initiatives in Africa - (2002-2014). Int J Drug Policy. 2016;27:132–7. governance, priorities, harmonisation and alignment. BMC Health Serv Res. 37. Fan VY, et al. Performance-based financing at the Global Fund to Fight 2016;16(Suppl 4):212. AIDS, Tuberculosis and Malaria: an analysis of grant ratings and funding, 66. Lawson ML. Foreign aid: international donor coordination of development 2003-12. Lancet Glob Health. 2013;1(3):e161–8. assistance. Washington, D.C: Congressional Research Service; 2013. 38. Fan VY, et al. Dedicated health systems strengthening of the Global Fund to fight 67. GMS. Grant Management Solutions. 2016 [cited 2016 10 November]; AIDS, tuberculosis, and malaria: an analysis of grants. Int Health. 2017;9(1):50–7. Available from: http://www.gmsproject.org/gmswebsite/. 39. Kiefer S, et al. Operational and implementation research within Global Fund 68. Initiative 5%. Initiative 5% SIDA, Tuberculose, Plaudisme. 2016 [cited 2015 27 to Fight AIDS, Tuberculosis and Malaria grants: a situation analysis in six July]; Available from: http://www.initiative5pour100.fr/en/frances-commitment/ countries. Glob Health. 2017;13(1):22. france-and-the-global-fund/. 40. Atun R, Kazatchkine M. Promoting country ownership and stewardship of 69. Averett, S. and B. Rivers, The Aidspan Guide to Obtaining Global Fund- health programs: the Global Fund experience. J Acquir Immune Defic Syndr. Related Technical Assistance, Global Fund Observer, Editor. 2004, Aidspan: 2009;52(Suppl 1):S67–8. Nairobi, Kenya. 41. The Global Fund. Implementing Partners. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/implementers/. 42. The Global Fund. Organizational Structure. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/organization/structure/ 43. The Global Fund. Technical Cooperation. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/fundingmodel/ technicalcooperation/. 44. The Global Fund. Technical & Development Partners. How We Work 2016 [cited 2015 25 October]; Available from: http://www.theglobalfund.org/en/ technical/#related-resources.

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