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 ManagerGlobal Fund Programme UnitUNDP ZimbabweTel: 263-4-792681/6 Ext 326Fax: 263-4-7286695

OCTOBER 2007.

TABLE OF CONTENTS

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

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

II Round One Phase One Resources…………………………………..7

III Global 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

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Abbreviations

AIDS Acquired Immunodeficiency SyndromeART Antiretroviral TherapyARV Antiretroviral drugs ASOs AIDS Service OrganisationsCBOs Community Based OrganisationsCCM Country Coordinating MechanismDPR Designated Principal RecipientESP Expanded Support ProgrammeGFATM Global Fund to Fight AIDS, Tuberculosis and MalariaGF Global FundHIV Human Immunodeficiency virusIOM International Organisation for MigrationLFA Local Fund AgentLPAC Local Project Appraisal CommitteeMOHCW Ministry of Health and Child WelfareMCAZ Medicines Control Authority of Zimbabwe MDG Millennium Development Goals NAC National AIDS CouncilNatPharm National Pharmaceutical CompanyNATF National AIDS Trust FundNGOs Non-Governmental OrganisationsPLWAS People Living with HIV and AIDSPMTCT Prevention of Mother to Child Transmission of HIV PSM Procurement Supply ManagementPR Principal RecipientSRs Sub RecipientSSRs Sub sub RecipientsTB TuberculosisTORs Terms of ReferenceTPR Temporary Principal RecipientUNICEF United Nations Children’s FundUNAIDS United Nations Joint Programme on HIV and AIDS UNDP United Nations Development Programme VCT Voluntary Counselling and TestingWHO World Health OrganisationZACH Zimabbwe Association of Church related HospitalsZAN Zimbabwe AIDS NetworkZNFPC Zimbabwe National Family Planning AssociationZNASP Zimbabwe National HIV and AIDS Strategic Plan

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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$ 3,497,411.87 in 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 GutuGlobal Fund Programme ManagerGlobal Fund Programme UnitUNDP HarareTel. 263-4-792681/6 Ext. 326Fax. 263-4-728695E-mail:felicity.hatendi-gutu@undp.org fhatendi@ecoweb.co.zw

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I. 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.

2. 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.

3. 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.

4. 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 124 rural districts, as opposed to supporting fragmented projects. Support was also provided for the capacity strengthening of the National AIDS Council,

1 Zimbabwe Demographic Health Survey 2005-2006.2 Zimbabwe Central Statistical Office (CSO) July 2007),3 Guided by exchange of letters between Global Fund and UNDP Headquarters of 16-17December 2003 and Government of Zimbabwe and UNDP 4 Beitbridge, Binga, Chiredzi, Chimanimani, Kariba, Mangwe, Mt Darwin, Mudzi, Shamva, Zvimba, Zvishavane, Makoni districts

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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.

5. 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.

6. 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

7. 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.

8. Zimbabwe’s application to the Global Fund of US$ 218 million was turned down in 2004. This triggered debate 7on 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.

9. A total of US$ 10.3 million was approved for Round One Phase One for a two-year period. Of the

planned total of eight disbursements two were made. The first US$ 4,333, 341.00 was disbursed in May 2005 and US$ 3,497,411.87 in November 2007 with 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

5 Implementation, Procurement and Supply Management Plan 2005-20066 Government of Zimbabwe and UNDP Programme Grant Agreement – Annex 3: Terms of Reference GFATM Project Positions7 Southern African News Features – SANF 04 no 88, October 2004. Selective application of Global AIDS fund likely to reverse gains.

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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.

10. 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.

A t 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

11. 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

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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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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 person8. The GFATM unprecedented

8 The Herald (Zim) 5 June 2007. Title: HIV/AIDS: Holistic approach vital

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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.

III. GFATM GOVERNANCE INSTITUTIONAL ARRANGEMENTS

17. The main body of this paper will focus on the in-country institutional GFATM governance9, 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

18. The Local Fund Agent (LFA) an international accounting firm based in Zimbabwe is 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

19. The LFA strengths were found in the following areas of financial 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:

20. Amongst the governance challenges of the LFA in country included the following:

9 Understanding the institutional dynamics of South Africa’s response to the HIV/AIDS pandemic (Strode & Grant 2004)10 Conditional grant refers to a grant transferred with specific conditions on what and how it is spent. 11 Good Governance principles include accountability, transparency, leadership and management, participation, effective partnership building, representation, decentralization of power and institutional responsiveness to mandate.

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i. The lack of ethical and moral responsibility to the GFATM external stakeholders including the indirect and direct grant recipients of the grant, partners, and other affected groups who were directly or indirectly dependent on it for perceived services. The LFA was not considered a public institution by virtue of it projecting its self as the “eyes and ears of the GFATM”.

ii. The LFA was solely accountable12 to the GFATM, having made a commitment to respond to it and focused its accountability on the GFATM at the expense of the in country stakeholders.

iii. The organization had different levels and types of responsibilities that appeared to conflict at times including the regulatory responsibility to the Government of Zimbabwe in complying with certain regulations, contractual and legal responsibility to the GFATM, financial responsibility to donors or shareholders. As such made frantic attempts to “please all”

iv. LFA was unable to live up to the in country GFATM structure expectations which included the need for accurate, timely GFATM communications, sensitization, education and information of the GFATM Geneva expectations and governance instruments and tools. The LFA was expected to interpret and contextualize these tools whilst providing leadership and guidance, with respect to GFATM programme management. The LFA was not an "agent" in the true sense of the word and as it is not empowered to represent the Global Fund's views or make decisions regarding grants. Information about this body was largely unknown during the grant cycle, resulting in different and often conflicting roles for the LFA seen as members, spies, observers, and or technical advisor13.

v. The LFA appeared to suffer from its inability to manage power imbalances between the organization and its internal and external stakeholders, including funders, and beneficiaries.

vi. The Agent lacked familiarity with GFATM programme operations, including administrative structures and processes through which in country policy design, implementation, monitoring and evaluation was undertaken. Limited interaction occurred between the LFA and TPR to enable the LFA to fully understand the UNDP Programme policies, procedures and guidelines. Thus making them prone to what was perceived as uninformed decisions, which, further strained the in country relationships. Among the performance based funding key LFA roles include that of asking; whether key indicators have been met, if not, why not? Is this reasonable in the circumstances. For example limited attention was given to the to the process indicators by the LFA following a request to the PR to stop reporting on them made in Quarter 3 of 2005. In Quarter Four a new GFATM template was introduced focusing on the 13 key indicators. For a balanced picture of the GFATM programme it is necessary to report on both the key and process indicators and elicit reasons for programme deviation and comments from the grant implementers particularly those at the project grassroot level on a regular basis. Hence the LFA was seen as requiring a higher level of GFATM programme management competencies and skills, information and knowledge particularly in the disease area of HIV and AIDS. The LFA did not conduct any field visits as means of verification of financial and programme reports. This activity would have been an important source of information, knowledge for this accounting firm and staff assigned to the GFATM project and served to enable the LFA to interact meaningfully with the PRs, SRs and SSRs and gain useful insight to programme challenges. Attendance at the CCM meetings by the LFA was adhoc again, the LFA missed opportunities to relay critical

12 Securing greater accountability is increasingly seen as an essential element in improving system performance. However, there are different forms of accountability, which depend on different types (administrative, financial, political) and directions (horizontal, downwards, upwards) of accountability relations. These, in turn, imply specific configurations of power and particular roles for different stakeholders.13 Regional Meeting for Southern African ‘ Sharing Innovative Solutions for Enhanced Program Delivery”, Windheok Nambia, 8-10 May.2007

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information, provide updated GFATM governance instruments and tools and verify programme issues.

vii. The organizational structure was unknown although and generally shrouded with secrecy and lacked transparency.14 The LFA was not open about its activities, the extent to which it provided information on what it is doing was limited, where and how this took place, and how it was performing. This was basic information necessary to enable the monitoring of the LFA’s activities by other GFATM stakeholders in country and would have enabled assessments to be made on whether its performance was related to the targets set.

viii. The LFA was perceived as a bureaucratic structure, slow and unresponsive to the PR needs, although there was a focal person assigned to the GFATM programme, whose terms of reference were unknown. Among the needs included that for urgent programme clarifications, authorization, target alterations, approvals, and GFATM permission for budget reallocations. The PR was informed that any communications on these and similar issues should be channeled through the LFA. Who would then review and finally (hopefully) communicate the request to the GFATM. The GFATM would deliberate and with no turn around time given would respond accordingly. Example: The PR wrote in March 2006 to the LFA to seek approval for GFATM programme component budget reallocations. The LFA sent the communication to the GFATM. PR informed to await a response (no timeframe given). In August 2006 during a GFATM mission visit to Zimbabwe the GAFTM tells PR to undertake long awaited budget allocations . The lack of a sense of urgency in the TPR requests lead to programming execution delays in SR training (s) planned and demotivated staff as salary adjustments could not be made in the absence of GFATM communication and written approval.

ix. The roles of the LFA in country were not clearly articulated and communicated. It was only in the GFATM letter15 to PRs, SRs and all CCM chairs in the Southern African Region that some attempts to clarify the LFA roles were made. Whilst this 2006 letter alluded to the dos and don’ts of the LFAs it left the PRs in a situation where GFATM guidance often sought in the day to day management, and implementation of GFATM policies and strategies remained to a large extent unanswered. This often left the PR with a need to directly initiate communication with the Global Fund Secretariat.

x. A holistic understanding of the needs and interests of the lower GFATM institutional arrangements responding to HIV and AIDS would have increased the LFA accountability. There appeared limited commitment by the LFA to institute mechanisms and reforms that would have enabled it to act more responsibly. The LFA did not make known to stakeholders the mechanisms that would have enabled stakeholders like the PR, CCM to input into decisions and recommendations made to the GFATM that affected them, thus not encouraging full participation.16

xi. Mechanisms through which the LFA enabled GFATM stakeholders to address complaints against recommendations provided to the GFATM or GFATM decisions and action taken and through which these complaints could be reviewed were not clear. A case in point is the rationale behind the two out of eight disbursements during the two-year period. Efforts were made to inform and communicate to the GFATM through the LFA and to date the LFA appears powerless to reverse decision made or expedite disbursements.

14 Transparency – The provision of accessible and timely information to stakeholders and opening up of organizational procedures, structures and processes to their assessment.

15 11 September 2006 Subject: Clarification of the role of the Local Fund Grant. 16 Participation- The process through which an organization enables stakeholders to play an active role in the decision making processes and activities which affect them.

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xii. The LFA suffered from communication challenges with an aversion to written correspondence and commitments brought about a general feeling that the LFA in country was truly “ceremonial”, or lacked clarity of its terms of reference. Communication was one way, with little or no feedback over lengthy periods of time. The LFA was expected to share recommendations made about the country structures. These communication delays affected timely PR decision-making, ultimately affecting the SR and SSRs rate of implementation and timely utilization of funds available. For example the local Ministry of Health the PMTCT component SR sought to ratify the PMTCT erroneous targets communicated and outlined in the GFATM Implementation plan of 2005-6. Official letters from the SR seeking approval for the proposed target adjustments to be made were sent in September 2006.To date October 2007 the PR has not received an official communication approving these changes from the GFATM via the LFA. As was usual practice no copies of the GFATM correspondence were copied to the PR. In yet another example the LFA sent e-mail communications of pending GFATM grant disbursements from April 2006 only for the disbursement to come in November 2007.17 No explanations were given by the LFA as representatives of the GFATM in country to the affected GFATM grant implementers including the grant administrators the PR. To date the PR has received no official communication on the reasons behind the Zimbabwean grant suspension or disbursement erraticness. An unanswered question which frequently arises from SRs and SSRs. Communication is a fundamental part of how governance systems operate in any political community and it is pivotal to state, civil society effectiveness, and public opinion as the basis of political authority. Alert, spirited and well-informed CCM, PR, and consequently the SRs and SSRs can influence the quality of governance based on two-way communication.

Country Coordinating Mechanism (CCM)

21. The Zimbabwe CCM has made enormous strides in ensuring that it followed the related and relevant GFATM requirements to ensure its eligibility for the Round One and subsequent grants.18 These include attempts to address adherence to the principles for CCMs, roles and responsibilities, structure, composition, and operationalisation of CCM principles. Amongst its roles include coordination of national proposals, selection of PRs, monitoring grant implementation, including approving major changes in the plans, evaluating grant performance (oversight), ensuring strategic partner building, linkages and consistency between Global Fund assistance and other health and development programmes in line with national plans, identification of financing gaps. The overall grant aim 19was to assist the CCM in the implementation as stated in the Government of Zimbabwe/UNDP Programme Agreement documentation signed September 2005. CCM meetings were held monthly and emergency meetings held on approval of the CCM Chairperson, with a quorum of at least 10 voting members. Invited guests, observers, technocrats were invited to CCM meetings and contributed to the discussion and debates but not vote. The current CCM Chairperson is the Minister of Health and Vice Chairperson from the WHO. Specific qualifications were met in respect to membership. Communication modes used between Secretariat and CCM members included mailing, fax, or email

17 Reference is made to paragraph 34 and 35. Fifth Board Meeting Geneva, 5-6 June 2003

18 Revised Guidelines on the Purpose, Structure and Composition of the Country Coordinating mechanisms and Requirements for Grant Eligibility – Incorporating CCM related decisions 10th Board Meeting, Geneva April 2005.19 Provide Assistance to the Country Coordinating Mechanism in the Implementation of the HIV component of the First Round of the Global Fund to Fight AIDS, TB and Malaria and strengthen and scale up disease prevention and care for HIV and AIDS in Zimbabwe

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and hand deliveries were made in special circumstances. CCM members are requested to forward information and communication amongst each other. The CCM in Zimbabwe is multi-disciplinary, cultural and sectoral. The 20 members represent different interest groups drawn from Government, non-government and community based organizations, academic and educational institutions, PLWAs, private sector, religious and faith based organizations, in country multilateral and bilaterals; and United Nations organizations. This often posses often personal and organizational agendas.

Strengths

22. Multi-sectoral, multi-disciplinary representation, country driven, presence and availability of locally adapted and user friendly governance instruments.20 The presence of strong visionary and innovative leadership to guide operations. The importance of CCM leadership was recognized through the appointment of the Minister of Health and Child Welfare as the Chair and WHO as the Vice Chairperson. Well constituted as according to the GFATM guidelines. CCM met monthly, decisions were taken by consensus reaching, rather than voting. CCM Subcommittee on HIV and AIDS is in place and consists of 12 members, functional as from Q7 of Round One, terms of reference and deliverables under refinement. This committee demonstrates the recognized need for the allocation of tasks by the CCM. CCM Sub Committee on HIV and AIDS consist of CCM members, and SR implementers. Facilitated the interaction between CCM and GFATM structures with regards to programme management issues. The presence of a resource constrained embryonic CCM Secretariat allowing for the undertaking of CCM communications targeting its membership. Provision of timely and accessible GFATM programme quarterly reports and presentations is made during CCM meetings. During these meetings efforts were made to ensure ongoing dialogue between CCM, PR, and SRs. CCM created a technical panel with the objective of helping in the preparation and the review of projects proposals.

23. The CCM exhibits transparency through ensuring that the TPR updates the CCM on GFATM programme information quarterly. TPR reports on the GFATM quarterly programme management progress, challenges and constraints with particular reference to the GFATM five component thirteen targets/indicators. The CCM acted as a mediator when conflicts arose between the TPR and DPR, TPR and the grant SRs. The CCM allowed the DPR and TPR acting as Chief Executive Officers of a Board but with no voting rights to ensure communication with the CCM was open, transparent, relevant, substantial and prompt. Element of transparency allowed for the TPR in the given allocated time during CCM meetings to make not only monthly presentations, but fully explain the reasons for any decisions or course of action taken during the management of the programme.

24. The Zimbabwe CCM managed to foster good working relations with its internal and external stakeholders, over the two-year grant period especially within the donor community in country. CCM made attempts to coordinate donor responses to the HIV and AIDS national response and in support of the GFATM programme. Other donor interventions often largely partial, selective and often resulted in parallel programming activities, appeared in direct competition with the GFATM conditional grant.

20 CCM of Zimbabwe Terms of Reference – approved January 2005Ethics and conflict of Interest Policy – Revised 10 August 2005Rules of Procedure –Approved 20 January 2005Guide for Constituency Member Selection to the Zimbabwe CCM

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For example the common funding approach of the Expanded Support Programme (ESP)21 on HIV and AIDS, within the Zimbabwe National HIV and AIDS Strategic Plan (2006).. Facilitated effective communication between Round One Phase One PRs and SRs, and instituted vigorous follow up with the GFTAM on conditions precedent and delays in quarterly disbursement of the grant. Hence ensuring timely GFATM programme and governance communication including feedback improvement. The CCM is currently reviewing the past state of operational affairs including the “Board” composition, communications, roles and responsibilities in relation to GFATM programme governance versus management.

Weaknesses25. Programme monitoring and evaluation22 and oversight role of the GFATM conditional grant was weak

as a result of inadequate or some cases absence of a CCM operational budget. The lack of which prevented the CCM undertaking field visits to verify data presented by TPR and DPR and technical staff and observers present at each CCM meeting. This inability resulted in over reliance on programme information that was provided by the PR, SRs who were members of the CCM and other interested and influential others.

26. Although 12 /13 Round One Phase one targets were met, the CCM was unable to develop mechanisms and undertake an oversight role to ensure the lagging behind achievement of the GFATM process indicators, These included the outstanding at programme close date April 2007 Youth and PMTCT component infrastructure rehabilitation and renovations, consistency in ARV supply, and procurement of programme commodities and supplies.

27. In some instances it became clear that the CCM leadership did not always have a clear or strategic grasp of the situation and was at times weighed down by its own red tape and bureaucracy. For example when GFATM funds were limited and not forthcoming, there was need for policy decisions to be made so that the limited funds in country could make a significant contribution and impact in the context of the overall development problem that of HIV and AIDS. Due to lack of informed and timely decision making the funds were spread thinly across the programme. At times the CCM discussions overly concentrated on programme issues, distracting members from their governance role.

28. The CCM before reconstituting the CCM Sub Committee on HIV and AIDS to which it then delegated its oversight role would over concentrate on GFATM programming and management issues to the exclusion of the undertaking of its governance role. Such as determination of in country policy and strategies, monitoring the grant performance, managing the governance process, and providing the TPR with much needed insight, wisdom and judgment.

29. CCM membership consisted of Round One Phase One grant Sub Recipients who represented their civil society, public, private sector constituents and had voting rights. This at times resulted in CCM

21 Expanded Support Programme- implemented by WHO, UNFPA, UNICEF, UNAIDS, IOM. Funded by Canada, Sweden, Norway, Ireland and the UK aimed at supporting scaling up access to prevention, behaviour change, treatment and care services in Sxpanded S22 Evaluation – relates to the processes through which an organization, with involvement of stakeholders, monitors and reviews its progress and results against goals and objectives, feeds learning from the back into the organization on an ongoing basis; and reports on the results of the process.

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members with special and narrow interests capable of driving the agenda towards and in protection of their interests. This hampered transparency, accountability and inhibited their full participation.

30. The benefits of a public- private sector partnership in Zimbabwe have yet to be realized. The private sector although playing important roles through augmenting resources, implementation of grants in the GFATM, remains weak in Zimbabwe, although private sector representatives participate as full members of the CCM.

31. The full participation and voices of People Living with HIV and AIDS was often muted and unheard, and equally of other female members of the CCM. What was absent were attempts to raise ware ness , acceptance and knowledge by undertaking lobbying and activist events. This could be that as females in a male dominated environment full of professionals; possessing low educational levels, inadequate programme and disease information, intertwined with gendered societal expectations and patriarchal social structures prevailing. They were not empowered to voice their concerns and advocate for their rights and as such their role in influencing the decision making and overall GFATM programme service delivery processes was minimal.

32. The CCM NGO23 representatives appeared constrained in the performance of their expected and varied roles. These included the furtherance of the social goals of their members or funders, provision of meaningful and informed contributions leading to the design and implementation of GFATM supported development, defense and promotion of a rights based approach to HIV and AIDS service delivery and provision particularly in a resource constrained environment like Zimbabwe. NGOs also posses a comparative advantage in that they can mobilize public support and voluntary contributions for aid and they have very strong links to the GFATM grant beneficiaries enhancing their representational roles. Importantly CCM NGO representative were expected to play an important role in ensuring participatory democracy. It was not evident the added value of NGO participation in the CCM. This was in contrast to the CCM members drawn from the International Non Governmental organizations. Independence should be a major attribute of non- governmental organisations and is the precondition of real participation. 24

33. Periodic reviews of the CCM and its committees performance against agreed list of governance responsibilities, structure and role of the CCM and its committees, composition to check whether the CCM members had the right skills and abilities, and assessment of the two way effectiveness of communication between TPR, DPR and the CCM was not done often enough. This had an impact on the quality of discussion, decision-making and policy formulation that occurred.

34. Although the Government of Zimbabwe is committed to partnerships, with government taking the lead, CCM partnership building, linkages with potential funders and resource mobilization was weak. This was as a result of the prevailing political climate and increasing international isolation of the country causing unnecessary dependency on GF funds, which were inconsistent and erratic. Local

23 Non Governmental Organisations – Term “non governmental organisation’ implies independence from governments. There are a heterogeneous group, with numerous classifications, commonly divided into Operational and Advocacy groupings. Main purpose to defend or promote a cause. NGOs vary in their methods and approach to health and development work. . Commonly possess two management trends : diversity and participatory management. The local NGOs are commonly funded by international Governments and private sector. 24 Agenda 21. Strengthening the Role of Non Governmental Organisations: Partners for Sustainable Development – United Nations Environment Programme

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funding sources such as from the National AIDS Trust fund 3% levy and state HIV and AIDS programme were reallocated to bolster intermittent critical shortages of ARVs. The NAFT income continues to dwindle as unemployment in the formal sector rises. There is need for development of mechanisms and or strategies to increased interaction and consultation with its external stakeholders importantly all recipients of grant, who are affected by the CCM decisions and activities but not fully represented in the CCM.

35. The level of participation in CCM meetings was hindered by the following inadequate access and availability of disease and GFATM programming knowledge, information, low educational and interest levels, politics of professional dominance in particular by the medical fraternity, which resulted often in minimal discourse and debate. TORs, GFATM policies and guidelines, constitution present, were not widely shared amongst members. Gender biases also created an unequal playing field for participation, with ensured full participation of backbenchers mostly who consisted of non-voting members, observers and invited technocrats. Level of education, familiarity of disease and subject matter tended to give medical fraternity members the upper edge on CCM discussions, decision making, on programme management issues and other HIV and AIDS technical areas. Thus leaving the majority of members including the PLWA representatives often silent, particularly as there was a gender balance in terms of those well versed with the topic and those less empowered. This key process requires a wide variety of local actors, at different decentralized levels, with different skills, background and experience and avoidance of medical dominance.

36. Participation of some CCM members was further constrained as it was difficult for one single representative to represent an entire sector like that of the civil society sector. For example in Zimbabwe the civil society sector consists amongst other groupings of media, representatives of the business sector, academics, religious bodies and their operational wings, farmers and grassroots movements, labour, student and consumer movements. Full not token participation in the proposal writing processes for example is necessary for to enable a bottoms up approach, inclusive rather than exclusive and targeted approach. This will increase institutional responsiveness as programming will focus where possible on identified, felt and expressed or otherwise GFATM beneficiary needs. Improved and decentralized communication, coordination and a truly multi-sectoral approach, will equally ensure adequate representation of all relevant partners at the table with regards to GFATM conditional grants. Other actors may bring importantly additional resources that will have a significant impact on existing HIV and AIDS prevention, treatment, care and mitigation activities. Proposal writing not decentralized fully, thus limited downstream participation, coupled with limited programme communication, poor or lack of modern communication technology.

37. The CCM was accountable in its actions to a variety of different constituencies including the GFATM, Govt. of Zimbabwe legislators and executive, relevant line HIV and AIDS Ministry and with indirect accountability to bilateral, multilateral funding GFATM country representatives who are full members of the CCM. It was not always clear who the local other sector CCM members were eventually accountable to as it is difficult to determine whether sectoral representative from of the CCM do in fact report within their sectors and what forms the feedback took. The lack of feedback from CCM membership constituencies would influence the level of knowledge and member debate and participation. CCM members are requested to forward information and communication amongst each other. Several representatives cited the need for support in acquiring communication technology.

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CCM debates and discussions only appeared in the minutes circulated by the CCM Secretariat with an absence of public communications using radio, TV, newspaper, open forum, debates, and decentralized activities. The general public requires information about the performance of their CCM representatives if they are to hold them accountable and able to influence importantly the quality of governance. There are no structural mechanisms that enable the general public to interact with the CCM and influence its agenda.

38. Quality of CCM of outputs and service was further compromised due to a lack of clear definition between the CCM governance roles and the PRs management roles.25 This lack of clarity frequently compromised the quality of debate and discussion. Members lacked information, knowledge about PR operations related to the GFATM programme and the TPR governance instruments. This usually was a bone of contention as the TPR was often accused of being inflexible, not responsive to the HIV and AIDS “emergency” situation in Zimbabwe, causing unnecessary delays in the procurement of essential medical items such as drugs as a result of using governance instruments that were to ultimately ensure accountability, transparency of actions to achieve the end.

39. Full knowledge of the CCM instruments by all hindered at times the full application of the governance instruments. On going communication and sensitization on the instruments is currently an ongoing process.

40. Broad based policy formulation, dissemination, implementation and enforcement is needed. The CCM often fell short of ensuring timely and responsive determination of policy and strategy complimentary to the GFATM/UNDP PR policies programme policy pronouncements, especially in an environment of rapid change, diminishing HIV and AIDS resource base. National, provincial, district level policies, guidelines and plans are needed by the PRs and SRs to guide effective implementation of HIV prevention and care initiatives. Determination of policies26 is one of the key governance roles leading to conducive policy environment. Operational challenges were encountered as a result of inadequate and lack of timely grant disbursements. In such situations of limited cash flow, high staff attrition detrimental to attainment of targets the PR commonly sought CCM GFATM administrative policies in line with the local laws, and statutory instruments and which conform to the local industry best practices. Decisiveness and consistency on the part of the CCM was often lacking.

41. Communication27 where there is free flow of information about public affairs, enables citizens to engage in debate and discussion about leading issues of the day such as the HIV and AIDS epidemic and the multi-sectoral response. This will result in competent citizens who will not tolerate misrule or abuse of resources. The media can be seen as a key to secure accountability within GFATM structures and amongst beneficiaries. Although the communication styles or channels are largely shaped by the disease. With civil society more conversant in using participatory AIDS education methodologies, where as the Government of Zimbabwe counterparts relying on more formal structured communication. The objective is to inform and heighten the levels of ‘good governance practices’.

25 Zimbabwe NGO Corporate Governance Manual

26 Meier (1991) – Framework describing five major steps in policy development: prediction and prescription, policymaker, policy choice, implementation and policy outcome.27 Background Note on Communication in Governance. World Congress on Communication for Development. Rome. Italy October 25-27 2006

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42. Element of grant (HIV and AIDS, Malaria) coordination was weak. Few efforts were made to bring all GFATM grant stakeholders together and facilitate the sharing of information, grant implementation experiences and ensuring of collaborative efforts in disease programme management. Weak efforts were made by the CCM to ensure GFATM linkages, strategic partnership development, and creation of opportunities for strategically piggy backing other existing national HIV and AIDS initiatives in order to heighten programme sustainability and financial stability. This by and large resulted in a silo approach to the GFATM contribution to the national response.

Principal Recipients -United Nations Development Programme (TPR), National AIDS Council (DPR)

37. Zimbabwe was in a very unique position in GFATM Round One Phase One. The Principal Recipient position was shared between two very different organizations one was a parastatal the National AIDS Council and a UN agency UNDP. UNDP as the TPR was directly and legally accountable to the GFATM, indirectly accountable and answerable for the financial and programme management to the CCM. Whilst NAC was directly accountable to the Ministry of Health and Child Welfare, the NAC Board, and indirectly accountable to every worker and business who pays the AIDS levy and corporate tax. Further indirect accountability of the NAC was to all beneficiaries of the NATF.28 The roles and responsibility and conduct of each PRs were clearly laid out29. Other PR roles and responsibilities are outlined in a standard individual SR Summary Letter of Agreement between UNDP (Principal Recipient) for GFATM and that of NAC as an SR. UNDP was to manage the grant using the direct execution (DEX) modality in the interim, within the context of the UNDP Country Programme Document. Resource mobilization efforts were made to ensure the NAC capacity was strengthened. UNDP was obliged under the agreement to work with the Designated PR NAC and this was achieved through a 14 staff GFATM Unit housed within both organizations but managed from UNDP.

38. UNDP agreed to undertake the following roles and responsibilities related to programme management: administration of GFATM grant, oversight, and support for M & E 30of SR implementers, procurement, and storage of non- medical items. UNDP as the TPR used its normal operational framework, its rules, regulations and procedures for the implementation of the GFATM financed projects. The UNDP governance instruments31 encompassed the UNDP/GFATM areas of operation in the following areas: financial, asset, programme, procurement and supply, and M & E. All documentation was availed to the SRs and sensitization and training on the governance instruments occurred within the GFATM budget allocated. Programme and financial progress reporting of the implementation progress vs. agreed plan, actual expenditures vs., budget and reasons for variance were submitted to the PR to the LFA no later

28 Zimbabwe National AIDS Council – Enacted through an Act of Parliament of 1999 (the National AIDS Council Act 15:14 of 2000), also mandated to administer the National AIDS Trust Fund collected through the AIDS levy from every workers taxable income (PAYE) and corporate tax.29 Government of Zimbabwe United Nations Development Programme Programme Agreement Document Part 1-5, Annexe 1-530 Monitoring and Evaluation- NAC guided Sub Recipients using GFATM M & E Tool Kit and national tools. Overall monitoring carried out by UNDP. Grant evaluation to be conducted at discretion of GFATM.31 UNDP Manual for projects financed by the Global Fund to fight AIDS, Tuberculosis, and Malaria, UNDP Financial Regulations and rules, UNDP Procurement Manual, Imprest Account guidelines, UNDP Programming Manual and Guidelines for processing VAT Refund claims

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than 45 days after the close of each of the eight quarters, together with Sub Recipient disbursement request. The UNDP partnership with the GFATM was premised on the organizational capacity development role.

39. Strengths : UNDP met the GFATM criteria to become PR following assessment by the LFA, received CCM recommendation to assume grant legal financial and programmatic accountability. UNDP is PR in over 100 other countries. Demonstrated ability to manage the GFATM programme in a harsh operational environment. Was supported by the UNDP regional centre, key UNDP-GFATM contacts at Headquarters and other Thematic centres providing policy and technical advisory services. Possessed minimum GFATM capacities, systems and requirements in the following areas; financial management and systems, institutional and programmatic requirements including information management systems (knowledge management and learning), procurement and supply management systems and audit, monitoring and evaluation. Participated with relevant others in programme design and hosted the UNDP Local Project Appraisal Committee (LPAC), which finalized the programme documentation. Facilitated (budget permitting) mid term and annual programme reviews with involvement of SRs, SSRs and other GFATM service providers to review the progress, and results against objectives.

40. The TPR was able to ensure the feeding back of lessons learnt, and facilitate the sharing of GFATM programming experiences and information through the UNDP knowledge and information management networks. Membership of these networks included all UNDP staff, staff from other UN organisations and other development institutions. Ensured a relationship between evaluation and accountability through learning. Ensured timely reporting to the GFATM through the LFA, duly informing the CCM. Demonstrated a commitment to transparency and accountability through supporting the undertaking of internal and external audits. Maximized on the use of the UNDP ATLAS tool for financial and programmme management and reporting. GFATM programme contributed to the Zimbabwe United Nations Country Programme outcomes. Continues to contribute to Millennium Development Goals32. Satisfactory programme performance cumulated in realization of 12/13 targets at programme end date of May 2007.

41. Compliance of GFATM/UNDP policies, guidelines and enforcement of stringent reporting requirements resulted in UNDP ability to adhere to governance principles. NAC strengths were the presence of decentralized structures in the 12 districts, which enabled GFATM support, M & E, vehicle management, coordination, undertaking of the Quarter six Accelerated Action to address target achievement in Round One Phase One.

42. NAC as the recognized national coordinating body and administering the NATF funds was able to compliment the GFATM grants and other donor supported programmes in support of the national response. NAC was able through the NAFT funding provision to provide additional funding for SSRs for district activities and chip in particular in October 2007 when GFATM funds dried up. Developed the Zimbabwe National HIV and AIDS Strategic Plan (2006-2010) and associated policy statements. Chairs the National and decentralized partnership forum and ESP working group. Has the legal mandate to coordinate the Zimbabwe multi- sectoral response to HIV and AIDS. Undertook the quarterly M & E data collection, analysis, report compilation and submission

32 Millennium Development Goals (MDG) Goal 6: Seeks to combat and reverse the spread of the HIV and AIDS epidemic. Goal3: Promote gender equality and empower women.

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to PR. Conducted quarterly decentralized coordination and GFATM integration meetings. NAC shared programme responsibilities through the GFATM Unit members housed, managed by NAC in conjunction with UNDP. Maintained close relations with the Ministry of Health and Child Welfare, and was familiar with the national HIV and AIDS programmes, policies and guidelines, challenges and constraints. Served to support UNDP in contextualizing the overall grant implementation.

Weaknesses:43. UNDP as TPR faced several challenges in undertaking the stipulated TPR roles and

responsibilities. Within the organization there were early challenges related to leadership and management of the GFATM. GFATM programme initially being managed by a UNDP Task Force with members holding other responsibilities within their respective positions. Recruitment and appointment of an International Manager for three months and finally the substantive appointment of a national Programme Manager in August 2006 to Round One Phase One programme end date April 2007. This lead to situations at times where the leadership and management was not constant not being able to give an account to, take account of and be held accountable by other GFATM stakeholders.

44. Challenges were also faced in the UNDP internal operating environment, in the undertaking Procurement, Supply and Management, oversight, support, M& E roles. Transparency was compromised, as the organization was often unable to provide accessible and timely programme information to stakeholders including the CCM encounters as a result of having delegated its responsibilities to other GFATM actors outside of its control.

45. The present of bureaucratic disbursement policies, processes, and procedures, often hindered participation of other key stakeholders to play an active role in the decision making processes and subsequent activities which affected them.

46. The TPR had a limited programme communication budget to enable the undertaking of needed GFATM social mobilization and advocacy activities. Communicating challenges were faced with SRs, who subsequently needed to communicate and obtain feedback from decentralized SSR structures in 12 rural districts.

47. This typical UN bureaucracy was centralized, based in the capital city of Harare with no sub offices, with mandatory reporting and accountability to UNDP Headquarters and the GFATM. Questions were often raised as to who the PR in Zimbabwe was as a result of strong reporting ties outside of the country. Accountability of the PR to the CCM was obligatory and fluid as the project execution modality was Direct Execution (using DEX), which required that UNDP enter into a legal agreement with Global Fund. UNDP was to respect the role of the CCM and urged to continuously keep the CCM informed about programme progress.

48. UNDP was unable to conduct as many support M & E visits due to GFATM staff constraints. Thus relied on NAC for programmatic progress information as agreed in project agreements. Whilst NAC continued to suffer high staff attrition, shortages of fuel and logistical support to support district level GFATM coordination, support and M & E activities. Centralisation hindered the PR direct interaction and communication with the grant SSR, who were contractually

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accountable to the Sub Recipient, who was accountable legally to the PR. A lot of time was spent in verification and communicating in some cases directly with the SSRs at the grassroots level by passing the SR, in order to expedite programme accelerated progress.

49. Overcoming grant recipients negative perceptions of UNDP as TPR was a major challenge. UNDP had limited resources for social mobilization, advocacy and development of programme integrated communication tools. For example the TPR was considered slow, rigid, in responding to the AIDS crisis which had been declared a national disaster in 1999 and in 2002 a state of emergency. This was for the purposes of procuring ARVs and scaling up existing interventions. The TPR level of responsiveness was deemed questionable in times of SR emergencies and in the implementation of CCM directives to the PR. The TPR made too many demands for compliance of UNDP/GFATM policies, rules and procedures, was not user friendly, rigid, a poor communicators and seen to develop self serving cumbersome procedures to be followed. Of annoyance to SRs and consequently SSRs was the deemed, over emphasize on governance aspects relating to accountability, transparency, efficiency and effectiveness, together with lengthy, rigid structured decision making processes. These perceptions caused a great deal of frustration among SRs and other GFATM partners and at times verbal resentment was targeted at the PR, causing unnecessary conflicts and temporary breakdown in relationships- particularly as timely disbursements were not forthcoming from the GFATM.

50. As a result of the limited GFATM capacity building/strengthening programme budget allocations few capacity development or strengthening initiatives were undertaken throughout the two years, despite the obvious need as a result of the ongoing professional brain drain in the country. GFATM/UNDP policies were not readily understood, internalised and accepted. For example Procurement, Supply and Management (PSM) policies, guidelines and procedures were not readily undertaken by SRs due to limitation in human capacities. As such often PSM roles and responsibilities were negated or delegated to the PR. The TPR GF Unit did not at times have the requisite staff relying on already overburdened but GFATM procurement trained staff who were also servicing the entire UNDP country office. This resulted in unnecessary procurement and supply delays as there was no sense of urgency in the GFATM requests. Insufficient funding also caused delays in the timely and adequate procurement of vital and scare medical commodities. Often incorrect procurement information was provided by SRs leading to the need for further communications requesting additional and verification of information provided among the SSRs. This took time often due to communication difficulties and high staff migrations necessitated the PR to continually train and provide and relay programme information.

51. Compliance was problematic and governance challenges were faced during the enforcement by the PR of Letters of Agreements and UNDP Administrative guidelines aimed at enhancing accountability, transparency and results management in UNDP operations 33 introduced in June 2006. The circular outlined the following measures that were implemented and communicated to all PR, SRs, SSR personnel involved in UNDP programming activities to ensure that appropriate controls were to be put in place and that all UNDP policies, rules and procedures were adhered to. SRs faced reporting and accountability challenges as evidenced in the internal and external audit observations as a result of weakening institutional capacities and limited resources in responding satisfactorily to the directive. The circular aimed at outlining elements of good governance

33 Administrative Circular Number:2006/009 Accountability, Transparency and Results management

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practices addressing the conditions under which UNDP as the TPR would provide resources to SR projects, make financial advances and direct payments, extend project life cycles, appointment of SR project focal persons representing the SR implementing partner, undertake M & E activities, undertake field monitoring visits, conduct the final, mid and annual reviews and meetings, conditions for the transfer/disposal of equipment purchased with UNDP funds and filing/recording systems.

52. UNDP agreed role to strengthening the capacity of the DPR NAC was partial achieved due to budget limitations, resource constraints. The enhancement of the NAC capacity sought to facilitate full integration and management of the GFATM, HIV and AIDS components into the national response. This poorly explained and or communicated inability to raise funds caused resentment and friction between the two PRs translating into governance challenges. At times challenging the degree of credibility and legitimacy of UNDP as a GFATM TPR.

53. The GFATM Global Secretariat structure is generally perceived by local SRs as bureaucratic, with communication challenges, demanding for “little money for a lot of work” with stringent governance requirements, responsible for the erratic and at times no grant disbursements, lacked responsiveness to PR and SR requests, and country demands and needs. Some of the GFATM demands felt on existing weak systems and capacities brought about resentment, diminished levels of programme ownership, commitment, and participation. This was further hampered by negative local private media reporting portraying GFATM as “inhuman”34 which equally put pressure on the PR to engage in damage control with the GFATM Secretariat to ensure continued and broken promises in relation to eventual grant receipt were realized.

Sub Recipients

54. There were seven Grant Sub Recipients35 consisting of government, non- governmental, private sector, parastatals, faith based organizations as recipients of grants. Contributing to the attainment of targets and the provision of HIV and AIDS GFATM component services. SRs were accountable to the PR and directly to their respective institutional governance Boards. Legal framework of recipient of grant funds was outlined in Letters of Agreement between UNDP and the said Sub Recipient. The Letter of Agreement,36 in accordance with the project document with terms and conditions served to confirm and communicate the acceptance of the SR of the services to be provided by the SR towards the programme/project. SRs had a legal obligation as a result of disbursements to use the funds and any other resources availed in accordance with the Principal Recipient’s rules and regulations. The Letter of Agreement further outlined the different roles and responsibilities of the GFATM key actors such as the CCM, LFA, and PR in respect to programme provision of the said services.

34 Daily Mirror, Zim Global Fund 17 November 2006. Global Fund has no heart. ..Sunday Mail (Zim) 03 December 2006 Zimbabwe Intensifies fight against HIV/AIDS35Zimbabwe AIDS Network (ZAN), National AIDS Council, (NAC) Zimbabwe Association of Church related Hospitals (ZACH), Zimbabwe Family Planning Council (ZNFPC), Ministry of Health and Child Welfare (MOHCW), NatPharm, Medicines Control Authority of Zimbabwe (MCAZ)36 Summary Letter of Agreement between UNDP ( Principal Recipient) for Global Fund to Fight AIDS., Tuberculosis and Malaria (Global Fund) and SR Inclusive of 10 provisions.

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55. Other GFATM/UNDP/governance instruments and tools were shared with the SRs. List of documents shared with SRs covered the operational framework, requirements of the UNDP financial regulations and rules, Procurement Manual, Audit and other oversight mechanisms. Importantly financial resource management information included modalities for reporting on programmatic and financial progress, programme expenditures, work plan, cash reconciliation, requirement, and seeking of authorization.

Strengths56. SRs consisted of local entities from local private, civil society, public sectors and faith based

Organisations and approved by the CCM. PR undertook capacity assessments and review of institutional structure, processes and mechanism for successful execution of grant. Participated in annual, quarterly review. Possessed decentralized structures, manpower and complimentary financial, logistical programme support. Proven track records in the execution of HIV and AIDS programmes and part of the multi-sectoral response. Possess elements of responsiveness in the provision of forms of support to those infected and or affected by the HIV. Proven resource mobilization potential to compliment grant funds as stated in Item 31 in the PR/SR Letter of Agreement.37

Weaknesses57. All SRs suffered from varying degrees of individual /institutional capacity issues largely as a result

of changes in the development assistance available in Zimbabwe from 2002. A decline in donor assistance resulted in weakened and declining support systems including program support mechanisms, human resources, financial management, procurement supply management, support monitoring and evaluation activities. The inadequacy or resources contributed significantly to compromised accountability, transparency of actions, participation levels, representation and SR organizational responsiveness to mandate.

58. Among the SR financial programme governance challenges faced were as a result of delayed or absence of the communication of the relevant guidelines. This was initially restricted to SRs; with the PR relying on SRs to disseminate the information to their SSRs. SRs cited shortages of fuel, and other logistical support resulting in SSRs38 the direct implementers at the lowest decentralised level being not informed on GFATM/UNDP expectations. The hyperinflationary environment that prevailed for the most part of programme implementation put pressure on the utilise the limited Phase one budget with the United Nations exchange rate adjustments not in line with inflation. The three month delay by GFATM to approve the SR Letters of Agreement (LOAs) negatively affected SRs & SSRs programme implementation as disbursements could not be made by the PR without signed LOAs. High exchange losses of US$678,767.98 were incurred during Round One Phase one to the depreciation of the local currency the 2007 exchange losses have yet to be calculated. There was a need for enhancing the SR and SSR absorptive capacities, budget analysis and

37 Item 31 states “ the SR recognizes that the GFATM awarded the programme funds that are subject of this Agreement on the condition that the grant is in addition to the normal and expected resources that the Host Country normally receives or budgets from external or domestic sources…”

38 Sub sub Recipients of GFATM Round One Phase one grant included SR provincial offices, NAC decentralized structures, ZNFPC provincial and district structures, Rural health centres, Mission hospitals, AIDS Service Organisations (ASOs), Community based organization (CBOs) operating in the 12 districts.

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effectiveness, promotion of good practices in tracking expenditures, monitoring performance and utilisation of the findings to adapt policies and necessary budget reallocation.

59. Financial reporting and compliance within the UNDP generally accepted accounting principles were a challenge for most SRs. Not all transactions it was noted in internal and external audits were transparent. SR financial sustainability efforts to reduce GFATM dependency such as costing of services provided, development of business ventures whose proceeds are channelled into the GFATM component work and local resource mobilisation were minimal. Fuel and vehicle management possessed governance challenges. Although efforts were made by the PR following the internal and external audits to provide technical assistance and support to counter these SR institutional management system and processes challenges.

60. Most SRs were highly centralized in the capital city Harare and other large towns yet providing GFATM services in twelve far flung rural, remote districts. This resulted in the lack of an oversight role aimed at improving the SSRs quality of governance. Limited decentralization and devolution of roles and responsibility and importantly decision-making with regards to the implementation, support, monitoring and evaluation of the programme affected implementation. Most SRs were not in touch with their SSRs there by limiting the amount of accessible and timely information reaching and coming back and forth and through decentralised implementing structures, partners and GFATM beneficiaries.

61. Participation levels in the SRs institution were largely unknown, though assumed together with the ability of GFATM grant beneficiaries’ role in the programme planning, implementation, monitoring and evaluation processes. As was the level of community ownership of GFATM HIV and AIDS programme initiatives and degree of involvement of People living with HIV and AIDS as a governance norm.

62. Organizational flow of HIV and AIDS information initiated by SRs, to SSRs, to beneficiaries heightens transparency. It was assumed for the greater part of the programme life cycle that SRs engaged and interacted with SSRs regularly. Limited attempts due to budget constraints saw the development and production of HIV and AID literature and community grass roots based and driven AIDS educational activities in support of the PMTCT, ART, VCT and Youth components.

63. SR knowledge and consequently compliance SR of the Letters of Agreement and other governance instruments was patchy. In a continually changing environment with high staff attrition rates in SR organizations, the need for individual and institutional capacity strengthening initiatives was critical. Limited national and GFATM resources hampered training and retraining of relevant project human resources. Resulting in resulted in depleted and other uninformed human capacities to execute and enforce governance instruments. Staffing issues also weakened SR responsiveness in the provision of GFATM HIV and AIDS component services across the board and necessitated the emphasis on participatory involvement of programme beneficiaries.

64. SRs faced governance challenges in the area of procurement and supply management. There was lack of transparency, participation of relevant others, absence of different types of skills needed to manage different types of goods and services, inadequate consultation with product end users, unclear roles and responsibilities of parties involved in PSM chain (GF, PR, SR, SSR, etc.);

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sufficient planning for forecasting of pharmaceuticals and procedures of forecasts. Insufficient planning for monitoring (detail, model, responsibilities, methodology and strategy). There was need for market and product knowledge for procurement and not just reliance on the undertaking of three quotations. It is about partnering with clients and supply sources. All these resulted in unnecessary delays encountered by the PRs and the procurement and supply of vital medical commodities such as needed ARVs. Transparent and professional procurement process was generally perceived as “one week exercise.”

65. Programme management challenges resulted in weakened accountability due to limited programme resources as a result of late disbursement of GF resources to SRs by the PR and diminishing complimentary SR component budget allocations. Implementation quality and quantity was affected, whilst the resource challenges at times affected the SR responsiveness, transparency ability to ensure the full participation of all infected and or affected constituents and organizational stakeholders.

Sub sub Recipients66. This diverse group of different, independent, autonomous entities were drawn from the public,

private and civil society sectors (local and international non-governmental organizations, Faith based organizations, AIDS Service Organisations, Community based Organisations) community groups and associations. Some were registered under the Zimbabwe PVO Act, others |were voluntary members of the nationally recognized HIV and AIDS networking and umbrella bodies. They were contracted by the SR and directly accountable to the SR for delivery of GFATM component services. The SSRs are direct and decentralized implementers of grant funds channeled through the SR through a binding Memorandum of Understanding and or a contractual agreement. This outlined the operations of the SSRs in the provision of services on behalf of the SR. Sub sub Recipients received GFATM grant disbursements, medical and non- medical for the execution and attainment of the programme targets.

Strengths67. Organisations with decentralized structures. Effected the scaling up of GFATM HIV and AIDS

prevention, treatment, care, and mitigation component. Ensured provision of services directly to grant beneficiaries at the district and grassroots level. Executed social mobilization, advocacy and community HIV and AIDS educational activities as a result of proximity to the affected and infected people at the grass root level. Undertook programme communication activities, and distribution of Information, Education and Communication materials. Able to achieve participation and inclusiveness in addressing community HIV and AIDS needs and concerns.

Weaknesses68. Amongst the weaknesses and governance challenges39 faced by this structure include:

Leadership and management challenges were faced in the SSR structures. Reliance on SRs to provide GFATM programme leadership, guidance and direction. Predominately there are males in leadership and management positions in the rural community structures. There is presence of gender imbalances in community decision-making structures leading

39 Zimbabwe AIDS Network Global Fund Review Dzimbahwe Lodge. 9 October 2007

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to absence of female voices and their and other marginalized groups such as people living with HIV and AIDS representation.3

In ability to engender ownership by SRS and subsequently communities of the Implementation plan 2005-6 as a result of limited participation in the proposal development. Necessitated the need for SSR adaptive planning, creation and sustaining of supportive linkages, partnerships and community based collaborative approaches in the multi-sectoral national AIDS response.

Working in largely improvised communities with limited access to the public sector HIV and AIDS resources, SSRs are resource constrained. This affects scaling, pace of accelerated actions, responsiveness and creates over reliance on the inadequate GFATM grant provision at this crucial level. Need to build stronger and more responsive accountability frameworks, budgeting systems, to facilitate much needed timely disbursements and enhancement of absorptive capacities.

SSRs are accountable to the GFATM SR as fund providers, with limited accountability to service recipients. This contract with the SRs precludes accountability to the PR except via the SR and with any other GFATM structure. SSRs face accountability challenges in their inability to respond to lower level and community views, concerns and needs. Do not participate in the decision making processes and structures and as such bemoaned the difficulties when confronted by communities to answers GFATM questions, decisions and policies made, relating to their operational activities.

Organizational capacities to deliver are declining in this poorly resourced environment. Compliance is affected in that staff attrition was problematic even within the decentralized structures, necessitating the need for regular institutional and individual capacity building and strengthening initiatives following periodic capacity assessments. Lack of sense of ownership of the GFATM interventions, encountering diminishing community ownership of the programme affecting, accountability and participation levels.

Participation limited as communities are pre-occupied with meeting basic survival needs. Full participation will ensure that GFATM programmes contribute in meeting the challenges of HIV and AIDS, without leaving out the poor, marginalized groups and those in the remote corners of the 12 rural districts. Limited participation is also linked to limited participation in the design, implementation, monitoring and evaluation of programmes.

Limited information as it is assumed that the SR has the resources and will to ensure that new GFATM information becomes available in a timely, user friendly manner to SSRS. Importantly the SSRs complained of timely dissemination of GFATM governance tools and this brought about a general sense of lack of awareness on what is happening, further affecting their ability to compile. SSRs on receipt of GFATM information are expected to disseminate this information using a variety of channels and modes to the GFATM programme beneficiaries.

Limited sharing of scare resources, joint planning, and implementation monitoring and evaluation activities with other similar and like community based structures. Problems of programme sustainability are encountered a result lack of independent or complimentary income to support GFATM programme administration and support activities.

Limited and problematic communication challenges with the GFATM accountable other the SRs, PR, CCM and the LFA. As a result of limited budgetary allocations and institutional resources to undertake regular community based reviews, information sharing and networking activities. Communication with GFATM communities proving costly and

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feedback limited. As there is need to travel long distances in an environment of logistical and fuel shortages together with overcoming of communication technology challenges commonly non functional, accessible, and available.

IV. CONCLUSION AND RECOMMENDATIONS

69. The Zimbabwe Government’s response to the AIDS crisis has been exemplary, in light of the low levels of funding, human resources and international support. Prevention and treatment initiatives have been scaled up and the national HIV prevalence has declined.40 . To sustain these multi-sectoral achievements there is need for continued and sustained local and international resource mobilisation. The GFATM remains an important funder and actor in this regard.

70. The continuing multi-sectoral development response to the epidemic requires recognition of governance as a continued challenge. To strengthen existing GFATM institutional “good governance” practices requires the internalization of these practices as processes rather than events or requirements or conditions precedent and involvement of all infected and affected people in the making of decisions that affect their livelihoods in a increasingly transparent and accountable manner. GFATM support is needed at the country level for the strengthening of institutional governance monitoring and evaluation processes based on the outcome of institutional appraisals. The GFATM should emphasize that grant recipient countries develop at least minimum governance standards and tools in its GFATM institutions.

71. The periodic evaluation of governance within the GFATM institutions and its impact on the national HIV and AIDS responses should be encouraged. Assessments should be undertaken of the quality of the governance information systems (from data collection and policy making) across GFATM grant recipient countries. This will form the basis for building capacities in governance monitoring, and allow for governments, CCMs in particular and other GFATM structures to better prioritse, monitor and develop governance indicators.

72. Each of the dimensions transparency, participation, evaluation, complaint and response mechanisms are necessary for GFATM institutional accountability41. As such there is room for the strengthening of these elements within the in country GFATM structures namely: LFA, CCM, PRs, SRs and SSRs.

73. Capacity development support to enhance leadership and management provided to these structures, institutions and processes is crucial particularly in resource constrained environments. Institutions cannot be effective unless appropriate systems and processes are in place to meet the needs of its target groups. Successful management of the funds requires GFATM support for staff recruitment, retention and development in leadership and management positions. The LFA should be capacitated to enable provision of independent advice as local experts42 as the GFATM does not have country-level presence outside its offices in Geneva.

40 UNAIDS (2005) Evidence for HIV decline in Zimbabwe: a comprehensive review of the epidemiological data 41 Pathways to Accountability – A Short guide to The Gap Framework42 The Global Fund to Fight AIDS, Tuberculosis and Malaria, 2003

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74. The full participation of all GFATM in country constituents, key actors, stakeholders and direct and in-direct grant beneficiaries involved in the application, execution, management and use of grant resources is a must. Communities should be empowered to actively participate in the SR decentralized structures and levels in grant decision-making processes and activities. Likewise there is need to engage them at the operational levels, the policy level and/or strategic levels. Fuller and broader, gender sensitive participation will ensure that the GFATM programmes compliment the national HIV and AIDS programmes, develop a more people centered approach and enhance transparency.

75. Representation of informed and empowered vulnerable groups such as those of People Living with HIV and AIDS, marginalized minority groups including women. Their voices must be heard in decision-making and the allocation of resources in all GFATM structures. This will result in raising the quality of debate and responsiveness of GFATM grant contribution and service delivery. This can be achieved through community capacity development43, social mobilization, advocacy and communication for social development initiatives.

76. SR and SSRs and other decentralized structures must be empowered and to enable them to demonstrate their proven ability to work with communities. Efforts should be made to strengthen provincial, district strategic planning and implementation and governance capacities for the GFATM support to Zimbabwe’s HIV and AIDS prevention care and support activities.

77. Accessible, available, user friendly and timely information pertaining to the GFATM operations in country together with the opening up of the GFATM organizational procedures, structures and processes for assessment will heighten the level of transparency. Continuing education, sensitization and information dissemination of the GFATM in country institutional governance policies and procedures, Fund Portfolio policies, and updated GFATM Geneva Board Decisions and Board approved policies by the LFA will enhance governance practices.

78. Improvement in the level of the GFATM organizational responsiveness is shown by the LFA, CCM, PR, SR response to the stakeholders concerns and needs. Thus there is a need to establish and strengthen the means and channels for identification and receipt of these needs. Responsiveness to the needs of vulnerable groups – women, children and rural communities requires that the GFATM actors provide easy and affordable access to medical treatment, rehabilitation and other forms of services to those living with HIV and AIDS. Grassroots beneficiaries must also have easy access to HIV and AIDS information, Good governance practices obliges the PR, SR and SSRs to respond with a variety of tools and approaches to counter the epidemic, one of which should be the participatory involvement of the infected and or affected people.

79. GFATM institutional programmes should respond effectively and efficiently to the HIV and AIDS epidemic, and be tailored to the country’s specific needs and political realities whilst addressing the immediate grassroots levels needs. SR and SRRs in Zimbabwe should be supported to continue

43 Community Capacity Development refers to “Strengthening, enhancing and nurturing a community’s abilities to take control of its own destiny and to manage and direct its development process through which an interactive process of assessment, analysis and action”.

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to employed and manage community groups, community based peer educators and counsellors who were able to scale up the GFATM component interventions and adopt best practices dependent on the availability of information sharing and networking and GFATM actor collaborative activities.

80. Decision makers at the national, provincial, institutional levels must be held accountable to the people and all stakeholders. This can be through increased involvement of grant recipient beneficiaries, stakeholder involvement in production of local national GFATM grant proposals and budgets. Allowance should be made for examination of public accounts including the NATF and GFATM grants outside of the formal structures such as the CCM. Strengthening of capacities to produce GFATM funds reports, financial audits. The undertaking and information dissemination of periodic internal audits managed by the PR, external audits, impact monitoring and evaluation activities form a basis for information with its constituents, including the CCM thus ensuring transparency in the operations of the grant. To ensure public knowledge CCM membership are urged to disseminate information on the grant operations to their interest groups and constituents. Accountability can be ensured through strengthening of SR and SSR financial and accounting systems, annual reports and conducting of independent audits which are made public. It is important that GFATM structures and development funds are accountable to their beneficiaries and as they are public funds and must be able to stand up to scrutiny. There is need for balanced emphasis on accounting for grant and the determination of the GFATM fund impact on the lives of the poor through achievement of goals and targets.

81. There is need for technical and financial support for the CCM to undertake policy dialogue and formulation, participation, planning and finance and research whilst incorporating cross cutting issues such as communication, gender, conflict management and intersectoral linkages. This will ensure that national HIV and AIDS responses are sustainable, long-term not short-term stopgap measures. There is need to strengthening linkages between GFATM structures, institutions and processes to the national policies and the nature and extent of relationships between the structures and institutional processes governing, managing and coordinating AIDS related strategies.

82. The GFATM is urged to provide its promised financial contributions to the Zimbabwean efforts to strengthen its national response to HIV and AIDS. Taking into consideration that all ongoing efforts are being made by key GFATM actors and stakeholders to strengthen and institute good governance practices and adherence to principles.

Acknowledgements44 and Disclaimer.45

44 The Author will like to acknowledge contributions to this paper from members of the Zimbabwe Global Fund Unit, SRs, SSRs and relevant others.45 The opinions, views, comments, suggestions and recommendations do not reflect the official record of UNDP’s views.

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