Governance of Hiv and Aids Responses: Making Participation and Accountability Count

GOVERNANCE OF HIV AND AIDS RESPONSES: MAKING PARTICIPATION AND ACCOUNTABILITY COUNT.

EXAMINATION OF THE ZIMBABWE GFATM INSTITUTIONAL ARRANGEMENTS

Felicity L. S.HATENDI GUTU.

Harare, Zimbabwe.

Global Fund Programme Manager

Global Fund Programme Unit

UNDP Zimbabwe

Tel: 263-4-792681/6 Ext 326

Fax: 263-4-7286695

OCTOBER 2007.

TABLE OF CONTENTS

Abbreviations…………………………………………………………………..4

I Introduction………………………………………………………….6

IIRound One Phase One Resources…………………………………..7

IIIGlobal GFATM Governance Institutional Arrangements…………10

Local Fund Agent…………………………………………………….10

Country Coordinating Mechanism…………………………………13

Principal Recipients…………………………………………………19

Sub Recipients………………………………………………………23

Sub sub Recipients…………………………………………………26

VI Conclusion and Recommendations………………………………28

Abbreviations

AIDSAcquired Immunodeficiency Syndrome

ART Antiretroviral Therapy

ARV Antiretroviral drugs

ASOsAIDS Service Organisations

CBOsCommunity Based Organisations

CCM Country Coordinating Mechanism

DPR Designated Principal Recipient

ESP Expanded Support Programme

GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria

GF Global Fund

HIV Human Immunodeficiency virus

IOM International Organisation for Migration

LFA Local Fund Agent

LPAC Local Project Appraisal Committee

MOHCW Ministry of Health and Child Welfare

MCAZMedicines Control Authority of Zimbabwe

MDG Millennium Development Goals

NAC National AIDS Council

NatPharmNational Pharmaceutical Company

NATF National AIDS Trust Fund

NGOsNon-Governmental Organisations

PLWAS People Living with HIV and AIDS

PMTCT Prevention of Mother to Child Transmission of HIV

PSM Procurement Supply Management

PR Principal Recipient

SRs Sub Recipient

SSRs Sub sub Recipients

TBTuberculosis

TORsTerms of Reference

TPR Temporary Principal Recipient

UNICEF United Nations Children’s Fund

UNAIDS United Nations Joint Programme on HIV and AIDS

UNDP United Nations Development Programme

VCT Voluntary Counselling and Testing

WHO World Health Organisation

ZACHZimabbwe Association of Church related Hospitals

ZAN Zimbabwe AIDS Network

ZNFPCZimbabwe National Family Planning Association

ZNASP Zimbabwe National HIV and AIDS Strategic Plan

ABSTRACT

The Global Fund To Fight AIDS, Tuberculosis and Malaria (GFATM) approved the Zimbabwe Round One HIV and AIDS proposal in 2002. Phase One grant funds were released after a series of specified conditions precedent were met. Phase One first disbursement US$ 4,333,341.00 was made in 2 May 2005, the second US$ 3,497,411.87in November 2006. Implementation commenced with the Zimbabwe National AIDS Council, the National HIV and AIDS coordinating body appointed as the designated Principal Recipient and UNDP as the Temporary Principal Recipient and the requisite GFATM governance institutions and arrangements established. The GFATM grant augmented the existing conditional grants made through the National AIDS Trust Fund and national fiscus. Zimbabwe was able to achieve 12/13 targets at the Round One Phase One programme end date of 30 April 2007, in a very difficult operating environment.

The objective of the paper is to contribute to the strengthening of country level GFATM institutional dimension of governance relating to the administrative structures and processes. Information was gathered and compiled from existing GFATM institutional guidelines, papers and outcomes of GFATM grant implementer workshop and meetings. The main body of the paper examines currently emerging common values of governance including accountability, transparency, leadership and management, participation, effective partnership building, decentralization of power, representation and institutional responsiveness of the Global Fund institutions and related organs at the country level. It highlights the strengths and weaknesses of these governance structures in the implementation of the national response to HIV and AIDS. Recommendations are finally made to all actors involved in the application, execution and management of good governance norms. In conclusion governance issues will continue to be decisive in shaping the Zimbabwean HIV and AIDS multi-sectoral response and remain key challenges to be addressed in this ever-increasing resource constrained environment.

Felicity Hatendi Gutu

Global Fund Programme Manager

Global Fund Programme Unit

UNDP Harare

Tel. 263-4-792681/6 Ext. 326

Fax. 263-4-728695

E-mail:

1. INTRODUCTION

Background and Context

1. Zimbabwe has a total population of 11,750 million and reports the fourth highest HIV and AIDS prevalence rate in the world. The AIDS prevalence rate among adults has declined from 21% to 18.1 % in 2006.[1] AIDS related diseases continue to cause the death of approximately 3 200 per week with over one million children orphaned as a result of AIDS. The current HIV and AIDS situation is compounded by increasingly hyperinflationary environment of 7,634.8%[2] declining economic performance, high unemployment, fuel, food, drug and foreign currency shortages, brain drain, and declining health sector service provision. The current situation has brought about development challenges as result of deteriorating key social and economic indicators and notable gender inequalities.

1. The response to the HIV and AIDS epidemic began in earnest in 1987, with the establishment of the National AIDS Coordination Programme (NACP). Policy framework that guided implementation of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) grant assistance included the National HIV and AIDS Policy of 1999 and the National HIV and AIDS Strategic Framework 2000-2004. A decentralized Zimbabwe National AIDS Council (NAC) was established by an Act of Parliament in 1999 and mandated to coordinate the national multi-sectoral response to HIV and AIDS. To date the NAC remains the main institutional response amongst other sectoral arrangements in the HIV and AIDS national response. The National AIDS Trust Fund (NATF) 3% monthly AIDS levy from formally employed people is administered by the NAC Secretariat which is the operational wing of the NAC Board and augments the Ministry of Health and Child Welfare HIV and AIDS national programme budgetary allocation.

1. The Zimbabwe Round One HIV and AIDS proposal was approved by the GFATM in 2002. Phase One grant funds were released after a series of specified conditions were met. Initially the Zimbabwe National AIDS Council, the National HIV and AIDS coordinating body was appointed the Designated Principal Recipient (DPR). This decision was reversed as a result of its lack of capacity to manage and administer the project and the CCM with the agreement of the GFATM subsequently appointed UNDP as the Temporary Principal Recipient (TPR). UNDP administered [3] the grant funds from the Program start date of 1 May 2005 to April 30 2007.

1. The first round grant funds supported the implementation and scaling up of interventions focusing on strengthening existing prevention of HIV among young people, provision of Community Home Based care (CHBC), scaling up of anti-retroviral therapy (ART), expansion of Voluntary Counselling and Testing (VCT) services, Prevention of Mother to Child Transmission (PMTCT), in Country Coordinating Mechanism (CCM) selected 12[4] rural districts, as opposed to supporting fragmented projects. Support was also provided for the capacity strengthening of the National AIDS Council, GFATM coordination and Capacity building of GF Unit .The programme objectives, inputs, outputs and impact were stated in the operational workplan.[5] The GFATM programme management arrangements were adhered to as stated in the Programme Grant Agreement documentation and the day to day management of the grant was undertaken by a GFATM Programme Unit with staff positions divided between UNDP and NAC.[6] GF Unit staff are housed at UNDP, and attached to other grant recipient organisations.

1. The GFATM programme was implemented by a select range of Sub Recipients (SRs) and decentralized structures Sub sub recipients (SSRs) drawn from the public, private, and civil society sectors. The SRs operated under signed governance instruments. Attachment 4 of the agreement outlined the SR schedule of services, facilities and payments. Other additional United Nations agencies, parastatals and specialist institutions, partners provided special programme services by agreements. UNICEF under took the procurement and supply of medical items whilst UNDP procured and arranged clearance on non-medical commodities as outlined in the Procurement Supply and Management plan. NAC guided SRs in the programme monitoring and evaluation of the components using the GFATM M & E Tool kit and national M & E indicators and data collection tools. UNDP was responsible for the overall supervision and monitoring of SR activities with NAC.

1. In an increasingly internationally politically and economically isolated country following the commencement of the Land Reform programme of 2002. GFATM grants applications are seen as a means to augment the declining (in real terms) state funds and National AIDS Trust Fund 3% levy funding. These local funds were set aside and targeted prioritized HIV and AIDS programmes in the areas of prevention, treatment care and mitigation.

II.ROUND ONE PHASE ONE RESOURCES

1. The GFATM in country institutions namely Local Fund Agent, Temporary Principal Recipient, Designated Principal Recipient, Sub Recipients were directly or indirectly charged with the institutional governance of three GFATM programme resources namely (i) financial, (ii) human and (iii) materials resources.

1. Zimbabwe’s application to the Global Fund of US$ 218 million was turned down in 2004. This triggered debate [7]on the selection criteria used for the allocation of much needed international resources to badly affected third world countries like Zimbabwe. The debate on donor politics was resuscitated in a country, which was reeling from international criticism, but needed additional funds, earmarked for scaling up the provision of treatment, care and ARVs to those affected and infected.

1. A total of US$ 10.3 million was approved for Round One Phase One for a two-year period. Of the planned total of eightdisbursements two were made. The first US$ 4,333, 341.00 was disbursed in May 2005 and US$ 3,497,411.87 in November 2007with less than six months remaining before the end of the grant period. Interest received over the two-year period totaled US $ 63,701.29. Total receipts for the programme amounted to US $ 7,894,454.16.. Financial grant disbursements were advanced, direct payments and reimbursements made by the TPR to the SRs, who in some cases sent funds further down to the grassroots operational level under separate SR and SSR agreements. Ultimate legal accountability for all grant resources lay with the TPR UNDP.

1. The Zimbabwe grant disbursements were characterized by the following:

• The programme received a total of US$7,830,752.87 in two tranches from the Global Fund. Amount received represented 76% of the Phase one budget of US$10.3 million. The undisbursed amount that remained with the GFATM out of the US$10.3 million grant was US$2, 405,545.84.
• The programme spent cumulatively US$6,151,470.68 representing 78.6% of the two disbursements received from GFATM and 59.7% of the planned budget (US$10.3 million) for Phase one.
• The TPR disbursed cumulatively US$2,236,013 (63.5%) to Sub Recipients compared against the SR agreements cash disbursements budget of US$3,522,223.
• The delivery rate for the Youth and PMTCT components were low because of the exchange losses realized on the advances. Total exchange losses represented 9.2% of the funds received from the GFATM.
• US$348,000 was disbursed to the responsible SR in September 2005 and only US$76,041 was utilized and the balance was lost as an exchange loss.This was for the renovations and sporting facilities activities in the 24 youth centres. The Youth Component low delivery rates were achieved on the salaries budget lines due to the salaries not being pegged to the US dollar and high project staff resignations.
• For the VCT component a significant amount of the budget saving was from the Primary Care Counsellors (PCCs) allowances, which were set in local currency at a scale much lower than the budget and the fact that the PCCs were in place for 14 months out of the planned 18 months.
• The low delivery rate under the PMTCT component was due to the completion of renovations in only five out of the planned 36 health sites.
• The activities that were not undertaken in the CHBC component included the procurement of four consignments of food packs and bicycle spares.
• The ART component shortage had a delivery rate of only 60.1% because the anti-retroviral (ARV) drug procurement over the two years amounted to only US$885,002.38 when the budget was US$1,894,966. Savings in ARV procurement arose from the falling ARV prices (prices for some drugs were at a third of budget) and the slow rate of initiating patients in ART in the first five quarters of programme implementation.
• At 30 June 2006, the project had spent cumulatively US$6,151,470.68 (78.6%) out of the US$7,830,752.87 received from the Global Fund.The Global Fund project delivery was at 56.5% at the end of 2006.
• As at 30 September 2007, the project had spent cumulatively US$6,401,154.08 (81.7%) out of the US$7,830,752.87 received from the Global Fund.

Human Resources

1. Grants funds secured the provision of services through the recruitment and employment of over 1104 community based support staff hired through SR contractual arrangements. Recruited staff were deployed in all the twelve rural districts and decentralized GFATM operational structures. The TPR made attempts to retain them, usually dependent on the availability of GFATM funds, timely SR disbursements and reporting of advances made. Dependant on the presence of efficient and effective human resource management capacities within the responsible SR. The public and civil society sector ability to retain staff under current remuneration packages and conditions of service has continued to decline. Primary Care Counsellors, Peer Educators, PMTCT/VCT/ART focal persons received GFATM supported competitive packages including incentives, allowances and US$ pegged salaries. In a bid to move with hyper-inflationary environment.

Material Resources

1. Relevant project materials, goods, equipment, software, furniture referred to as non-medical commodities were procured and supplied by UNDP. Medical commodities including anti-retroviral drugs, PMTCT test kits, laboratory reagents and equipment were procured using grant funds by UNICEF and other UNDP suppliers. Management, storage and distribution were undertaken by select SRs.

1. The programme received its second and last disbursement in Round One Phase One in November 2006. This put the TPR, SR and SRs under immense pressure to achieve in an increasingly hyperinflationary environment and very unrealistic expectations of SRs and SSR institutional absorptive capacities. The Global Fund reportedly suspended disbursements to Zimbabwe pending the introduction of a Flexible Exchange Rate Mechanism in order to reduce the exchange losses but later decided to release funds when the project had run out of funds and when it was due to submit its Phase Two Request for Continued Funding.

1. Inadequate and or lack of planned and promised GFATM financial resources, caused programme management challenges in PR, SRs institutions, as efforts were made to keep the programme on track for 18 months.The GFATM grant supported staff in the districts became demotivated, and some left never to return. The grant suspension compromised the TPR, SRs and SSRs’ ability to plan, execute, support, monitor and evaluate activities that were wholly dependant on those funds over that period. Achievement of targets slowed down as GFATM stakeholders continued to “lose faith in the GFATM”. The discontinuation of the grant caught the national authorities and CCM by surprise at a time when the Zimbabwean dollar was increasingly losing its value and no contingency measures or plans were in place.

1. No comments were made by the Local Fund Agent, as the “eyes and ears” of the Global Fund, to the local GFATM stakeholders as a public relations exercise or to seek to maintain a degree of accountability and transparency as expected governance roles. Although there were unofficial and unconfirmed reports that 2005 disbursements were delayed because of the late signing of agreements between sub-recipients and sub-sub recipients.

1. Not only were the GFATM grant disbursements to Zimbabwe erratic they were grossly inadequate for the severity of the HIV and AIDS epidemic. This was cited in a local daily report in comparison to other countries in the Southern African region.The Global Fund allocation in other countries is US$210 per person and yet Zimbabwe gets a paltry US$10 per person[8]. The GFATM unprecedented action, continued to anger grant beneficiaries as the majority of HIV and AIDS intervention programmes throughout the world are funded at the multilateral or bilateral level, and

this was not the case with Zimbabwe.

1. GFATM GOVERNANCE INSTITUTIONAL ARRANGEMENTS

1. The main body of this paper will focus on the in-country institutional GFATM governance[9], which refers to the administrative structures and processes through which policy design, implementation, monitoring and evaluation are undertaken. These structures directly or indirectly affected the effective and efficient utilization of the GFATM conditional grant.[10] The institutions examined are the Local Fund Agent, Country Coordinating Mechanism, Principal Recipients and Sub Recipients who are involved in the contextualization of HIV and AIDS interventions and approaches within the broad principles of good governance.[11] Finally the paper will discuss the governance challenges faced by the SSRs as direct implementing entities of the grant Round One Phase One grant allocation to Zimbabwe.

Local Fund Agent

1. The Local Fund Agent (LFA) an international accounting firm based in Zimbabweis generally perceived as the pseudo GFATM in country, and the eyes and ears of the Global Fund (GF). It is known to offer a wide range of audit and assurance transactions, crisis management, performance improvement, tax and human resource services, tailored to suit the industry or sector that it is offering these services to. The Local Fund Agent has a contractual and legal responsibility to the GFATM, and financial responsibility to donors and GFATM stakeholders to ensure that their money was used in the agreed way. It is directly accountable to the GF. In its contract with the GFATM the LFA was understood to provide grant financial management oversight, undertake grant negotiations, assess the Principal Recipient's capacity to implement the grant, review proposed budgets and work plans, independently oversee program performance and the accountable use of funds (known as Verification of Implementation). Included in their scope of work was the review of the Principal Recipient's periodic requests for funds, undertaking of site visits to verify results and reviewing the Principal Recipient's annual audit reports. All services are deemed crucial in assisting the Global Fund Geneva to make its decision on whether to continue funding beyond the first two years.

Strengths

1. The LFA strengths were found in the following areas offinancial verifications, reporting, auditing, accounting, and financial analysis. The LFA acted on request as the mediator (passing of verbally and written communications) between the PR and the GFATM in Geneva and others in country structures particularly the CCM.

Weaknesses: