The Global Fund is definitely a large and complex ecosystem. While they may be necessary, Global Fund policies are not always understood, accessible or accepted. Such is the case with the Challenging Operating Environments (COE) policy and the Additional Safeguard Policy (ASP). What do these labels really mean? What are the specificities, the differences, the goals and the challenges? How well do we think these different policies are working, several years after they were first applied?

As much as the COE policy promises innovation and flexibility, the ASP seems to contradict this by being quite restrictive. However, as you will see in the table below, of the 29 countries currently characterised as COE, 21 are also under the ASP, i.e., 72%.

To many stakeholders, the simultaneous application of the two policies in the same country appears to be a paradox, and even a profound contradiction with important consequences. A country representative who didn't want to be named said of this dual application that "it is giving with one hand what is quickly taken away with the other".

Before going further, let's start by defining the different policies.

Challenging Operating Environments (COE) policy

Approved by the Global Fund Board in 2016, the COE provides the Global Fund with differentiated operational approaches to improve the effectiveness of its programs and at the same time maximise its investments in countries or regions experiencing extreme emergencies or acute or chronic instabilities. The following list describes situations that are typical of what is meant by the term "challenging operating environments”.

Currently, 29 countries – of which 16 are African – have been identified as subject to this approach. Although they represent less than 14% of the world's population, COE countries have nearly one-third of the global burden of HIV, TB, and malaria and account for approximately 30% of Global Fund allocations: Afghanistan, Burkina Faso, Burundi, Central African Republic, Chad, Democratic People's Republic of Korea, Eritrea, Guinea, Guinea-Bissau, Haiti, Iraq, Lebanon, Liberia, Mali, Myanmar, Nicaragua, Niger, Nigeria, Pakistan, Palestine, Sierra Leone, Somalia, Sudan, South Sudan, Syria, Ukraine, Venezuela and Yemen.

The COE Policy is fundamentally built around three essential elements

1. 1. Innovation

The Policy’s normative and operational design allows for innovation. It permits the Global Fund to apply new approaches and mechanisms in response to the challenges that characterize a context. While in absolute terms Global Fund programs and investments always try to consider the uniqueness of countries, the COE approach is more pronounced when it comes to challenging implementation contexts. Thus, the approaches and operational mechanisms (design, management, external monitoring of grants, etc.) for implementing Global Fund programs applied in Mali will not necessarily be the same as those  in Nigeria or Ukraine. This idea of innovation is closely linked to another essential element: flexibility.

2. 2. Flexibility

The Policy’s design also allows for operational flexibilities:

• Limited liability clause
• Waiver of Co-Financing Requirement
• Program Data Verification Waiver
• Direct selection and appointment of Sub-recipient (SR) and service provider
• Waiver of Country Coordinating Mechanism (CCM) Eligibility
• Extension of audit report deadline
• Personalized approach: 24-month planning instead of three years
• Interim salary support for national staff for salary harmonization
• Selection of partners by the Principal Recipient (PR) based on partners pre-selected by the Emergency Fund pre-qualified partners.
• Regional Dialogue Waiver

Unlike traditional Global Fund approaches, in difficult contexts the application documents are tailored, timelines can be extended, administrative burdens are reduced, and contractual arrangements are simplified to provide services in hard-to-reach and insecure areas. It should be noted, however, that the policy is not a list of flexibilities that countries can choose at will. This is far from the case. Flexibilities must be justified, i.e., they must respond to contextual difficulties and thus to the need for a responsive and differentiated approach to ensure service effectiveness.

3. 3. Partnerships

While this approach allows a great deal of flexibility in the choice of partnerships, it also calls for the systematic integration of operational collaboration with development, humanitarian, private and non-traditional partners.

Source : Global Fund

Despite its good intentions, however, the Policy has strategic and operational shortcomings, concluded a recent evaluation by the Global Fund's independent Technical Evaluation Reference Group (TERG). We reported extensively on this in an article published in GFO 420, which you can find here.

A comparative analysis of the ASP’s implementation demonstrates that countries under this policy fall into categories. Countries are either under ASP because of chronic political instability or because of financial malfeasance that could undermine the results of the global partnership. However, in the history of the Global Fund, there have been cases where countries have not been placed on ASP for any of the reasons mentioned above.

Indeed, in 2017 the Republic of Congo was placed under measure for the following reasons:

"The government's difficulties in honouring its co-financing commitments despite intense advocacy by the Global Fund and its partners, which has notably led to a situation of stock-outs of antiretroviral drugs for adults and anti-tuberculosis drugs. This situation, which has persisted for several years, is aggravated by the economic and financial crisis that the Congo is experiencing.

Significant weaknesses identified in the supply management system: a review conducted by the Local Fund Agent at the end of 2016 revealed very significant weaknesses in the supply chain, illustrated in particular by the fact that antiretroviral drugs for adults financed by the government and anti-tuberculosis drugs financed by the Global Fund were found in certain markets.

Difficulties encountered in recent years in establishing a solid partnership with the Government of Congo, in particular difficulties for the Ministry of Health in recent years to fully fulfil its role as a pilot in the fight against the three diseases and to demonstrate, through tangible actions, its desire to strengthen the partnership with the Global Fund. Without denying the existence of the above-mentioned difficulties, the Global Fund nevertheless wishes to underline the significant improvement in the dialogue with the Ministry of Health over the last few months, and hopes to be able to continue and strengthen this constructive relationship.”

More recently, the Global Fund recently placed Burkina Faso under an ASP. In a December 2022 letter to Burkina Faso's Minister of Health and Public Hygiene, the Global Fund stated:

1. The Global Fund Secretariat will work with the Ministry of Health and the renewed CCM, Principal Recipients, programs, and Partners to identify and contract with relevant humanitarian, international, and local organizations (through a service delivery contract) to ensure implementation of activities in security-challenged areas during the remaining period of implementation of current grants; that is, until the end of December 2023.
2. The Global Fund Secretariat may, through Principal Recipients, explore and contract with international and local humanitarian organizations (if possible) as service providers to ensure coverage of health care and health products for displaced persons in different regions of the country.
3. The Global Fund Secretariat will explore the possibility of contracting, if necessary, through Principal Recipients; with humanitarian NGOs and UN Agencies in the Logistics Cluster as well as relevant private entities, to support the safe distribution of health commodities to displaced or hard-to-reach populations.
4. The Global Fund Secretariat may disburse funds directly to Service Provider Organizations for the implementation of targeted activities under contract.
5. The Global Fund Secretariat will decide on an approach to selecting the Principal Recipient(s) for the 2023-2025 allocation period and will nominate or select the Principal Recipient(s) for the next grant implementation period as necessary."

When applied, the ASP gives the Global Fund a number of important prerogatives. It allows the Global Fund to play the lead role in identifying and deciding on implementation arrangements, including the selection of PRs, SRs and other implementing partners, the establishment of fiscal agents/trustees, the use of the pooled procurement mechanism, and the application of the Conditional Cash Flow/"zero cash flow" policy.

The "zero cash flow" policy can also be implemented when the Secretariat applies the ASP to a given country; however, applying the ASP does not automatically lead to a "zero cash flow" policy.

For the Global Fund, invoking the ASP is always contingent on a risk assessment. Below is a schematic of the steps involved in the assessment and the process for applying the ASP.

Source: Global Fund

As can be seen, despite some overlap, the COE policy is not similar to the ASP. However, the COE policy, and the ASP in particular, have been the subject of a number of complaints for several years, and the Global Fund cannot ignore them. We recently published two articles highlighting recriminations against the ASP, one about Burkina Faso and the other about Burundi.

What is the basic problem with the ASP?

The African Constituency Bureau (ACB) has probably best expressed reservations - and the limitations and challenges – about this Policy. In a document for the preparatory meetings of the Global Fund’s May Board meeting, the ACB says:

"Twenty years after the Global Fund began investing in our countries, the risks of grant fraud and contracting do not seem to be disappearing. Worse, in countries subject to the ASP, where the Secretariat literally picks the implementers and contractors, gives a no-objection notice before most activities take place, and exercises other forms of control directly, the risks continue to materialize in creative ways.

The latest Office of the Inspector General (OIG) investigations revealed the theft of malaria nets in Guinea, a decade-old ASP country where an international nongovernmental organization selected by the Secretariat is the primary beneficiary. The nets were diverted for sale in neighboring Mali, a country also managed by the ASP.

Some will say that without these measures, other risks will materialise. Others will say that the risks have materialised because the mitigation measures leave significant gaps that the Secretariat is unaware of. It is likely that all would agree that this policy, adopted in 2004, needs to be evaluated after 19 years of implementation. Is it fit for purpose? What is working well and what is not? Are we getting value for money?

This assessment is especially necessary because the list of ASP countries largely overlaps with the list of difficult settings. These difficult settings countries represent approximately 30% of the Global Fund's allocations and 30% of the global disease burden for the three diseases. We must be successful in achieving our objectives in countries classified as difficult settings and managed by the ASP.

This position is far from new. For several years now, countries have been calling on the Global Fund to develop an exit strategy - with clear milestones that could be independently verified - and, above all, an evaluation of the policies. In order to move forward, it is sometimes necessary to look in the rearview mirror.