MAXIMIZING POSITIVE SYNERGIES - World Health Organization

Results
Leadership and Governance
Data showed that GHI governance was an important determinant of impact. PEPFAR’s leadership
and management structures were cited as integral to the rapid increase in the number of people
on antiretrovirals (ARVs) in Kenya. The Global Fund leadership and management structures were
perceived as presenting persistent challenges to achieving the full potential of its funding.
Informants indicated that it was relatively easy to communicate and problem-solve with PEPFAR
representatives, due to the established relationships with US government (USG) agencies in Kenya
and the resultant familiarity with their organizational structures. Access to PEPFAR leadership,
however, was somewhat hindered by its location in the US Embassy compound and the associated
security protocols. Respondents indicated that unclear mandates and poorly delineated roles and
responsibilities of the USG agencies—US Agency for International Development (USAID), the
Department of Health and Human Services (HHS), Centers for Disease Control and Prevention
(CDC), Walter Reed Medical Research Institute, Department of Defense (DOD), Department of State
and Peace Corps—created interagency tension and competition that led to inefficiencies.
However, informants also reported that these agencies’ scope of work was better defined and
clarified over the past year, and that this may help reduce tensions.
Unlike PEPFAR, the Global Fund does not have in-country representatives. All concerns must be
raised with the main in-country governance mechanism, the Country Coordinating Mechanism
(CCM), or by contacting the country portfolio manager in Geneva. Additionally, any programmatic
changes after the initial grant approval must be directed to Geneva for review, which causes
delays in implementation and reporting. Although informants believed that the Global Fund
country portfolio manager in Geneva was accessible and receptive, they indicated that Global
Fund-funded programmes would significantly benefit if portfolio managers were located in Kenya.
The Global Fund CCM elicited both positive and negative assessments from respondents. Some
informants lauded the creation of the CCM as a country-led team that brought together different
stakeholders in the health system and enabled donor resources to be better aligned with national
health priorities. Others felt CCM members did not adequately represent the different sectors
within the health system and that the government representation was disproportionately large.
They suggested that the CCM was a parallel system that was imposed by the Global Fund and that
it did not fit with the pre-existing national structures, since it only coordinated activities around
three diseases rather than across the entire health system.
Civil society organization (CSO) representatives to the CCM were elected democratically, however
the CCM chair and vice chair were not elected. Informants indicated that there were tensions
within the CCM, including a lack of trust between CSO and government representatives. Many
CCM members were members of the Global Fund sub-recipient organizations. Several informants
criticized CCM members who worked to benefit their own sectors exclusively or who attempted to
obtain Global Fund funds for their own programmes. Informants believed that this conflict of
interest hindered the transparent functioning of the CCM and the overall effectiveness of the
Global Fund in Kenya. Respondents criticized the CCM leadership for heavy infighting and
irregularities in reporting. Several respondents indicated that the CCM was not a legal entity and,
as a result, had unclear accountability.
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