The Global Fund Board held a Virtual Extraordinary Board Meeting (EBM) on Thursday 22 July 2021. This is the fourth Board meeting that has been held virtually due to COVID-19 and is the first virtual EBM. The meeting was held in the afternoon, Central European Time, and lasted for approximately three hours. The EBM agenda covered three related topics: (i) approval of the Strategy Framework for the next Global Fund Strategy, including discussion on the Framework ahead of the Board decision; (ii) Global Fund Strategy – Board guidance on additional topics and opportunity to provide an additional direction on priorities (not already raised) to be covered in the Strategy narrative, to be approved by the Board in November 2021; and (iii) the Strategy Framework Decision and next steps for the development of the Strategy narrative. In this article, we summarize the discussions held at the meeting and the main decision of the meeting, as well as the discussions held by the Constituencies in meetings prior to the EBM. This is followed by our third article written by the Global Fund Board Constituencies, explaining why they said ‘no’ to the Strategy Framework. Decision Point: GF/EB01-2021/DPXX: Approval of Strategy Framework 1

1. The Board notes the broad and inclusive consultations undertaken to inform the development of the next Global Fund Strategy, including the partnership-wide 2020 Open Consultation, 6th Partnership Forums, and extensive Strategy Committee (SC) and Board guidance.
2. The Board also notes that the Strategy Narrative will be developed based on the approved Strategy Framework and presented to the Board for approval, based on a recommendation from the SC, at its 46th meeting in November 2021.
3. Accordingly, based on the recommendation of the SC, as presented in GF/EB01-2021/02, the Board:

a. Approves the Strategy Framework presented in Annex 1 to GF/EB01- 2021/02 for the Global Fund Strategy covering the period 2023-2028; and b. Requests that the Secretariat develop, for the SC’s recommendation to the Board, the Strategy Narrative to further articulate areas of focus described in the Strategy Framework, based on input received to date through the Strategy development process. Pre-EBM Constituency consultations Since the EBM was convened to vote on approving the next Framework of the Strategy 2023-2028, several Constituencies held virtual pre-EBM meetings to be sure that the views of their constituents would be represented at what they felt was to be a ‘critical’ meeting. Nonetheless, the proposed revised Strategy Framework is still raising issues that stakeholders feel have to be articulated in the Strategy Narrative if their concerns are to be met, and Constituencies have laid out their views in position papers that were circulated prior to the EBM. Several versions of the Strategy Framework have been issued To remind readers of the timeline for the Strategy development, Figure 1 depicts the stage reached in the process:

Figure 1. Where we are in the Strategy development process

Constituents reiterated their positions at the beginning of the Strategy development process: that, as communities and civil society are the backbone of the responses to the three diseases and strong health systems, and global health security/solidarity depends on communities, communities must be at the centre of the next Strategy. Any expansion of the GF’s mandate must be contingent on additional resources. The next Strategy must: (i) provide clear guidance to partners on how to make equity, human rights and gender equality integral to all grants and national programs; (ii) guarantee community and civil society leadership at all levels of the Global Fund’s work and ensure this is supported with adequate resources; and put measures in place to evaluate investments and the impact of community systems strengthening (CSS) and community-led implementation and accountability. The Zero Draft Strategy Framework, presented to the 15th SC meeting earlier in March this year, made strenuous efforts to address these points:

Figure 2. Zero Draft Strategy Framework outline, March 2021

In response to this, some constituencies rejected a draft which put Pandemic Preparedness and Response (PPR) at a higher strategic level than communities and suggested that there had been ‘mission creep’, meaning, that the Global Fund had moved the parameters for its original mandate of HIV, TB, and malaria (HTM) to include PPR. They reiterated the call for the next Strategy to focus on the Global Fund’s primary mission and to put communities at the front and centre. They called for the Strategy to be grounded in core principles e.g., equity, human rights, solidarity, gender, and requested explicit goals to be added on CSS, human rights, and gender equality as key enablers to end the epidemics. They urged the Secretariat to clarify and define key concepts and terminology to avoid misinterpretation and reiterated the need to reach consensus on ‘how’ as well as ‘what’ ― proposed actionable steps to strengthen community-led responses. Based on this, the Strategy Framework was revised and a new version was considered at an Extraordinary SC Meeting on 30 June 2021. The GFO reported on this deliberation in an article Extraordinary Strategy Committee meeting discusses the revised Strategy framework published in issue #399 on 30 June 2021.

Figure 3. Draft 1 Strategy Framework outline, June 2021

Figure 4. Draft 1 Strategy Framework Strategic Shifts

The new version was welcomed by the Delegations who were pleased to see the centrality of people and communities within the primary goal and the contributory objectives on communities and equity/gender/rights (CRG). However, they still felt that their other concerns had not been sufficiently addressed: there was a continued lack of clarity about how to operationalize the new contributory objectives; concerns regarding the prominence and vague boundaries of the ‘evolving’ PPR objective; the Strategic Shifts (depicted above in Figure 4) focused on new or expanded areas of work rather than on how the Global Fund and partners would overcome existing weaknesses in implementation; and the Partnership Enablers (Figure 5 below) did not articulate the reforms required for communities and civil society to become truly equal partners.

Figure 5. Draft 1 Strategy Framework Partnership Enablers

This feedback resulted in a new version of the Strategy Framework that was submitted for Board approval in July 2021 and is depicted in Figure 6. In this version, it can be seen that Strategic Shifts have been removed from the Framework but the intention is to describe these in the Strategy narrative itself.

Figure 6. Draft 2 Strategy Framework outline, July 2021

Prior to discussing the proposed revisions and moving to a vote, the Executive Director of the Global Fund, Peter Sands, remarked on what is different in this proposed Strategy Framework. Proposed revisions The SC Vice-Chair summarised the SC discussions. The Strategy Framework is the vehicle for the most important issues that come through the Strategy Narrative and its implementation. Following the EBM, the draft Narrative will be developed and all constituencies will be able to review it and propose changes. In particular, she noted that the Strategy development process had been consultative and inclusive despite the challenge of COVID-19. There had been nine SC and Board meetings to discuss the Strategy, as well as the Sixth Partnership Forums. Accordingly, Strategy development had been informed by lessons learnt and all the findings and evidence were used by the SC to develop a robust Strategy Framework to be recommended by the Board. Amendment 1 The Communities Constituency had proposed an amendment to the title of the Contributory Objective ‘Increase resource mobilisation for health’ to remove the words ‘for health’. The Vice-Chair noted that this language will not change the intent behind the Strategy and therefore the decision before the EBM today incorporated this change. Amendment 2 The West and Central Africa (WCA) and East and Southern Africa (ESA) Implementer Constituencies had also proposed amendments to the Strategy Framework. However, these had only been received the night before the EBM, after the deadline. Hence, procedurally, it was the Board’s decision on whether or not it would agree to discuss the amendments before a decision on the amendments themselves could even be taken. Amid some confusion, the Secretariat clarified that the proposed amendments would be voted on in two parts: firstly, there would be a proposal to discuss the amendments; and, if the Board agreed to do so, the discussion would be followed by a vote on the decision points. It appeared that several Board members were not aware of or had not seen the proposed amendments. The two African Constituencies explained their issues, of which there were several:

1. The government implementer role must be named as being at the heart of providing services and setting policies and regulations. This would not detract from the stated roles of other stakeholders.
2. They emphasised the vital importance of health systems, which merits the provision of stand-alone support just as is provided for HTM, to ensure that we ‘strike a good balance’ between the systems within which diseases are addressed as well as the diseases themselves.
3. They wished to raise the matter of market-shaping, including local manufacturing of commodities and medicines closer to recipients.
4. Finally, they wanted to discuss the global disease split.

The Secretariat reiterated that this is what it calls a ‘gatekeeper’ issue and that the Board would have to vote on the motion to be accepted into a decision point. The moderator called for the motion to discuss the amendments to be proposed and seconded, which it was. However, no sooner had this occurred than someone raised the issue that, according to the Global Fund’s own procedures regarding the conduct of Board meetings, item 19.3 states that proposed amendments must be circulated to all Board members in advance of the meeting and this did not appear to have been done given that many Board members seemed to be unaware of them. Following the proposal and seconding of the motion to discuss the amendments, there was a lively discussion about procedures and the intent of the motion to discuss. The SC and the Board leadership explained that they felt they had to bring these amendments to the Board’s attention, even though they had been received at the eleventh hour, and even though their appearance was contrary to standard operating procedures. However, several members felt that this was setting a dangerous precedent for the Board’s future work. Why, they demanded, have these issues now been raised after 18 months of discussion? Some members felt strongly that, if the Board votes to bypass its own procedures, good governance goes out of the window. Many others disagreed with this point of view. One constituency member noted that most people have spent many years working within the Global Fund’s processes and tried their best to accommodate different viewpoints; and that this was especially important given the current challenging context of the pandemic. Others noted that it is not the first time that amendments have been raised from the floor: the Board needs to be flexible and listen to these amendments which, they felt, would improve the Strategy. Indeed, another constituency representative observed that this is consistent with previous approaches to the Board. The SC Vice-Chair remarked that this is a “friendly amendment” even though it had come too late for the SC to actually discuss it. There were many more interventions both for and against; however, when the Board eventually moved to a vote, not enough people supported the proposal to discuss the amendments that had been tabled from the floor. Hence, there was no discussion and that meant that the amendments themselves could not be approved. This is by no means the end of this discussion… In the somewhat shocked silence that followed the failed vote, the Board then moved to vote positively on the final decision point that had been shared ahead of the Board session, that of removing the words ‘for health’ from ‘increase resource mobilisation’. Moving from a focus on the Strategy Framework to the Strategy Narrative There followed a wide-ranging discussion on various issues that would be developed further in the Narrative, such as strategic shifts, PPR, the need to review the split between the diseases, and whether universal health coverage (UHC) should be highlighted as the Global Fund’s ultimate goal in the new Narrative. Nonetheless, casting a shadow over all of these discussions was the issue of COVID-19 and the awareness that everything had changed in the past 18 months, indeed, since the first discussions on the new Strategy Framework had begun. Next steps in the Strategy development process The timetable for the remaining Strategy development process is outlined in table 1.