USING KNOWLEDGE BROKERAGE

Understanding the role of evidence or when evidence counts in global development efforts seeking to address issues largely affecting the poor cannot be complete without an understanding of the voices of the affected countries in these processes. The role of global actors in tackling HIV/AIDS in developing countries provides an interesting case to understand how voices of affected countries inform the decisions made by global response efforts.

The 47 countries of sub-Saharan Africa hold two seats on the Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria. Collectively, the countries have been recipients of more than 65 per cent of Global Fund cumulative investment, making their input into the governance and decision-making by the Board critical to the Global Fund’s success. Language differences, a sub-par process for selection of leadership and a lack of technical support have inhibited meaningful participation.

To address these challenges, stakeholders developed a governance framework and established an Africa Constituencies Bureau to improve evidence-informed decision-making, build cohesion among the diversity of countries and improve the quality of input. This chapter documents the process by which the constituencies improved their evidence use in decision-making in order to share some lessons with other actors working in related processes.

Introduction

Understanding the role of evidence or when evidence counts in global development efforts seeking to address issues largely affecting the poor cannot be complete without an understanding of the voices of the affected countries in these processes. The role of global actors in tackling the HIV/AIDS, tuberculosis and malaria epidemics in developing countries provides an interesting case to understand how evidence, specifically voices of affected countries, informs the decisions made by global response efforts. There are some case studies in the literature documenting success using knowledge brokering for health policymaking in Africa (Van Kammen, de Savigny and Sewankambo 2006). There is, however, inadequate understanding of how knowledge brokerage could shape the engagement of developing countries within global decision-making processes.

This chapter discusses a case study of how African constituencies have engaged the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The case looks at how technical assistance, which is a brokerage function in the ecosystem of evidence use, was used to respond to the challenges that African constituencies faced in effectively engaging the Global Fund’s decision-making processes. We document the process by which the African constituencies improved their ability to use evidence in decision-making in order to share some lessons with other actors working within related processes.

The authors used document review, observations, interviews and personal reflections to inform the discussion, derived largely from their own experiences in actively helping to improve the use of evidence and to formalise the processes described. Danielle Doughman coordinates a team that provides technical support including evidence analysis and synthesis to the African constituencies engaged with the Global Fund; Kathy Kantengwa advises the constituencies from the Global Fund Secretariat; and, until recently, Ida Hakizinka chaired the task force charged with formalising the technical support mandate underpinning a coordinating bureau, and managed multi-country communications as the intermediary between the Global Fund and African constituencies.

Challenges to meaningful participation

The Global Fund was established in 2002 as a global war chest to pool and mobilise resources to respond to the three most prominent disease epidemics wreaking havoc across the developing world. Its governance structure comprises 20 voting Board seats, two of which are allocated to the constituencies of sub-Saharan Africa (SSA): one seat each for the East and Southern Africa (ESA) constituency and the West and Central Africa (WCA) constituency. Implementing countries from other regions hold a total of five additional seats.[1] The two Africa constituencies represent the 47 countries designated as SSA, and have, collectively, received more than 65 per cent of the more than $30 billion (Global Fund 2016) invested by the Global Fund since its inception. This means that their input into the governance and decision-making of the Board is critical to the Global Fund’s success.

Given the diversity of the countries that make up the ESA and WCA regions, their Board representatives routinely confront challenges that impede meaningful participation and engagement with the Global Fund Board, including a lack of adequate technical capacity, time and resources among Board or committee members. These challenges are enumerated in greater detail below.

First, the Africa constituencies’ governance framework requires that Board and committee members allocate 20–25 per cent of their time or roughly ten hours per week to Global Fund work.[2] This is a huge time requirement on the members of the African constituencies who have full-time jobs in their countries.

Second, language diversity presents a considerable barrier to effective communication within and across the constituencies. Official languages across the constituencies include English, French, Portuguese and Swahili, not to mention the array of national languages spoken by each member of the constituencies. Delegations comprising as many as ten people have varying degrees of proficiency in each of the official languages of the Global Fund: English, French and Spanish. Board documents are produced in English and French, but there is often a time lag between the release of the English-language and French-language documents, which presents its own set of challenges to multiple delegations, including the ones representing SSA.

Third, the Africa constituencies often confront hurdles with respect to the technical content in the thousands of pages of documents released by the Global Fund Secretariat ahead of Board and committee meetings. While many of them are highly skilled technocrats in their own right, representatives of government or non-governmental organisations or professionals with advanced degrees, the lack of synthesis of the many voluminous documents sent just before the Board or committee meetings reduces their ability to engage effectively in discussions and ultimately limits their influence on Board or committee decision-making (Garmaise 2012).

Fourth, efforts to ensure equitability in the choice of delegates and the appointment of Board and committee members, while laudable, have also unintentionally compromised the ability of the SSA delegates to contribute. Selection had previously been based on an alphabetical rotation of countries, rather than on interest, competency and capacity. According to a report from a 2012 Joint Constituency meeting, Board and committee members ‘often have limited knowledge or experience with the Global Fund’, and were ‘poorly prepared to participate meaningfully’ (Hoover 2012). Important Board decisions were made without adequate engagement of SSA representatives who, in some instances, voted against their constituency’s interests.

In a bid to address these challenges, the 2012 meeting provided impetus for a new way of working for the two constituencies, which resulted in the development and adoption of a joint governance framework in early 2013. This framework outlines selection processes for delegates and provides guidance for improved communication and more effective Global Fund participation in Board processes for the constituencies.[3]  Driving the development of this framework was the considered belief that good governance would increase meaningful participation and engagement of the constituencies in Board discussions, leading to smarter and evidence-informed investments in health in the region that would optimise impact in the eradication of the three disease epidemics.

The framework also establishes an Africa Constituencies Bureau (ACB): a technical resource centre able to provide support to delegates and constituencies as a whole to enhance participation in ensuing discussions at the Board and committee level and shape the development of policies and decisions by the Board itself for the Secretariat to implement. The mandate of the ACB is explicitly to identify ‘regional issues of relevance and significance… [and] support Global Fund document synthesis’ to improve understanding, and ‘review the implication[s] of Global Fund policy and strategies on Africa’.[4] 

Though not explicitly stated in the framework, a founding principle of these aims is to improve use of evidence as the basis for decision-making. This understanding has been borne out in the execution of the mandate, as African leaders steadily increase their requests for evidence related to Global Fund Board and committee decisions.

The adoption of the framework led to the establishment of a task force to lead the operationalisation of the ACB. The task force is composed of current and former delegates to the two constituencies and has received ad hoc support from a variety of sources, including the designated representative from the Global Fund Secretariat, the Ethiopian Public Health Association (charged with setting up a permanent ACB in Addis Ababa) and the African Population and Health Research Center (APHRC). Once the ACB is inaugurated, the task force will be dissolved.

A virtual bureau in the interim

In anticipation of the inauguration of the permanent, legal and physical ACB, and under the oversight of the task force, the APHRC was commissioned in 2014, first by the New Venture Fund and subsequently by the Bill & Melinda Gates Foundation, to provide technical support to the Africa constituencies in order to support meaningful engagement by delegates to the various Board and committee meetings each year. This tripartite arrangement between the task force, the Global Fund, and the APHRC is henceforward referred to as the Bureau.

By mutual agreement with the donor and constituency representatives, the Bureau develops briefing notes prior to Board and committee meetings;[5] coordinates consensus positions and talking points for debate and discussion on voting and non-voting issues; and assesses the potential impact of Board decisions on SSA. Complementary analyses are generated at the request of constituency leadership in response to important emerging topics. The Bureau helps to shape the focus and scope of analyses when needed.

The Bureau supports briefings of the constituencies prior to the twice-annual Board meetings, which also provide a space for delegates to deliberate about common positions on voting and non-voting issues at Board level. In addition, since 2015 the constituencies have convened twice to review the evidence and develop consensus positions on strategic and operational priorities for the Board meetings and other Global Fund engagement, such as the 2015 regional Partnership Forum, input from which shaped the 2017–2022 Global Fund Strategic Plan.

Examples of evidence-informed input and decision-making

There are almost unlimited opportunities to bring evidence and analysis to bear in Global Fund decision-making. Part of the challenge is determining what evidence is essential to informed decision-making, and to what degree to scale the information. Board and committee members are already inundated with information from the Secretariat. In an effort to alleviate some of the burden, the Bureau has focused on signature issues that concern most constituency countries. Signature issues, for the purpose of this chapter, meet three criteria: they are under discussion at either committee or Board level, and they have the potential for significant impact or resonate with current political or social realities. Three examples of evidence use for informed decision-making on signatures issues follow.

4.1 Delineating and communicating African priorities

In May 2015, the Africa constituencies convened a first-ever meeting to develop a joint position on issues of strategic importance, aiming to identify ways to optimise engagement by African delegations in the decision-making processes at the Global Fund Board. The consultation emphasised both operational and strategic approaches to this improved engagement, specifically related to the ongoing consultations around the development of the Global Fund’s own new strategy. The consultation was part of a series of global opportunities called Partnership Forums that were afforded to constituencies to contribute to discussions around the new strategy for the upcoming strategic period (2017–2022). In addition to erecting the meeting architecture, the Bureau provided a wealth of technical support, including real-time synthesis of information for feedback and thought leadership on areas of importance and diversity of opinion.

The statement that resulted from the consultative session was a watershed: a first nuanced and comprehensive articulation of joint African priorities and the rationale that led to them.[6] The statement was used to structure inputs from the African delegations to the Partnership Forum and, subsequently, to discussions about necessary revisions to the Global Fund’s strategy.

The statement asserted the issues of strategic importance to the Africa Constituencies as including the:

1.  Need for investments into stronger and more resilient health systems.

2.  Importance of programming that specifically targets women and girls.

3.  Need for a differentiated approach that responds to challenging operating environments.

4.  Imperative for countries to increase their own domestic financing of integrated, rather than vertical, disease-specific programming.

5.  Modifications to the Global Fund’s allocation methodology to ensure that the countries with the highest burden of disease and least ability to pay received the lion’s share of investments.

6.  Responsibility of a managed transition away from substantive assistance to countries improving their financial position as they become middle-income countries.

7.  Support for, and revisions to, the development of the concept notes, or proposals, resulting in investment.

Informal reports shared with the Bureau from the delegates indicated that the statement was well received in the context of the African Partnership Forum.

Ultimately, the unanimous approval of the 2017–2022 Global Fund Strategy at the 35th Board meeting incorporated five of the Africa constituencies’ seven strategic priorities. (The other two priorities were largely operational issues and addressed through other mechanisms). While the unanimous passage of the strategy demonstrates broad agreement across all constituencies that the priorities were the right ones for the Global Fund at this juncture, as well as the strong leadership by the Strategy, Investment and Impact Committee that led its development over the course of a year, the Africa constituencies were among the first to explicitly identify them. The re-centring of the Global Fund strategy on health systems and women and girls, it is hoped, will lead to dramatic improvements in health and wellbeing even beyond the three diseases, and beyond SSA, over the course of the next six-year strategic period.

Convenings such as the one that catalysed the creation of the priorities statement are a part of the governance framework. It dictates that the ACB shall provide ‘a forum for Africa constituencies to debate and discuss… and reach consensus’ on Global Fund topics and issues and to ‘[identify] regional issues of relevance and significance to countries to develop positions’.[7]  The second such convening was held in November 2016 and the priorities have been updated to reflect changing conditions:

1.  Strengthening Country Coordinating Mechanisms.

2.  Improving procurement and supply chain management cycle.

3.  Improving performance in high-risk environments.

4.  Building local capacity for greater sustainability.

5.  Improving country absorption capacity.

6.  Maximising Catalytic Funding for resilient and sustainable systems for health.

4.2 Using evidence to inform an African position on hepatitis C

The Global Fund Secretariat is mandated to provide background information about items that appear on the Board agenda. In 2014, the Strategy, Investment and Impact Committee was asked to consider whether the Global Fund should invest in hepatitis C treatment because of high rates of co-infection with HIV, particularly among people who inject drugs. The impetus for the request was driven largely by harm reduction activists working primarily in Eastern Europe and Central Asia, where hepatitis C treatment is seen as a central component of any response to HIV. At the time, investments in hepatitis C treatment were considered to be beyond the scope of the Global Fund mandate, even though it was indubitable that addressing co-infection of the two diseases could potentially reinforce gains in the response to HIV.

To inform the Africa constituencies’ position, the APHRC conducted a desk review to assess regional prevalence of hepatitis C. From the limited literature available at the time (Hanafiah, Groeger, Flaxman and Wiersma 2013),[8] prevalence was low compared to other regions, at between 1.5 and 3.5 per cent. Additionally, since the primary method of transmission of HIV in SSA is heterosexual contact, the level of co-infection is low; in other regions, where the primary method of HIV transmission is through the sharing of used needles among people who use drugs, rates are substantially higher – at up to 7 per cent of people living with HIV. Treatment for hepatitis C is expensive and time-intensive, and could further strain already weak health systems. Concurrent treatment of hepatitis C has been associated with poor adherence to and drop-out of HIV treatment programmes.

The evidence generated by the desk review determined that without commensurate investment in strengthening a health system’s capacity to effectively manage and monitor co-infection, investments in hepatitis C treatment programmes were expensive and would not yield an effective response. It further underscored the necessity of greater investment in health systems in the region – many of which were struggling to scale up coverage for testing and treatment, including prevention of mother-to-child transmission, and voluntary medical male circumcision.

The input from the African and other constituencies prompted the Board to defer its decision, in order to consider a wider mandate for contextual responses to a range of co-morbidities. The evidence-based position of the Africa constituencies in turn helped to influence the thinking of the committee and the Board to use epidemiological and clinical data to inform future decisions to expand investment in co-infections or not.

4.3 Analysis on country absorptive capacity

The problem of poor absorptive capacity plagues many countries in the region – in West Africa in particular. It should be noted that absorption is not a problem unique to the Global Fund or to Africa, but a problem common to development aid. An analysis by the Secretariat found grant absorption rates, or the percentage of actual expenditures compared to grant budget, to be 67 per cent over the course of 2015 in 11 francophone countries from West and Central Africa (Kampoer 2016). These countries were therefore convened to discuss their problems and develop solutions to improve absorption. Shared concerns from the Global Fund Secretariat and Africa Board members about poor grant performance, slow implementation and low absorptive capacity of grant funds prompted the Global Fund to host a forum in 2015, co-facilitated by the Bureau.

Ahead of the meeting, and in response to issues raised during the Partnership Forum, the Bureau conducted an online survey to understand the specifics of grant implementation in those countries. Results informed discussions around how to address the greatest country-specific bottlenecks in improving absorptive capacity. Countries then developed action plans to respond to their specific absorption bottlenecks.

The Bureau was asked to conduct a rapid assessment of the 11 countries for a follow-up meeting a year later, in June 2016, to assess country progress and troubleshoot any remaining challenges. The Bureau conducted key informant interviews with country representatives and a simple analysis to provide a status update on the implementation of the action plans and any residual challenges towards which more efforts should be directed, and shared the results at the second meeting in Dakar, Senegal. In tandem with these efforts, the Bureau completed a quantitative and qualitative analysis of expenditure data publicly available from the Global Fund to assess country absorptive capacity along with a qualitative analysis from two case study countries: Zambia and Burkina Faso.

Because absorption is such a critical issue for the Africa constituencies, the analyses have been ongoing over the course of 12 months and may be ongoing as constituency leadership raises new questions that need careful consideration. While the three analyses complement each other to form a more complete picture of absorption challenges, potential solutions and the state of implementation, gathering information has not been easy, and results have not been conclusive. One reason for difficulty in securing key informant interviews may be fatigue; 18 constituency countries are also participating in a Global Fund special initiative to, in part, alleviate absorption bottlenecks, and over the same time period. Another reason may be that constituency leadership who are requesting the analyses are unaware that their country representatives may be hesitant or refuse to speak with the Bureau about challenges, even confidentially. Such difficulties resulted in small sample sizes and the inability to draw definitive conclusions that have wide applicability to similar country contexts. However, the first online survey on absorption conducted in mid-2015 received 80 responses, signalling that confidentiality worries may be limiting the amount and quality of information derived from key informant interviews.

Despite the challenges, Africa is setting the tone not just for how the evidence is being used, but also for how it is being directed towards finding a coordinated solution to absorption that the Global Fund itself has not yet been able to fully address. Africa is generating and using its own evidence to develop its own, differentiated solutions.

So what? Evidence of initial impact

To help measure its effectiveness and draw lessons for improvement, the Bureau conducted a survey and key informant interviews. These captured feedback on technical support and on progress from key informants on observed changes in the voice and perceived influence of the constituencies at the board level. Though the sample sizes were small, they indicate that the support provided by the Bureau is having the intended outcome. Time will tell how that translates into sustained, meaningful impact.

The survey[9] assessed the effectiveness and outcomes of technical assistance provided over the course of four Board meetings, November 2014 to April 2016. All respondents agreed that their needs had been met well or very well for information synthesis, talking points and position statements for both Board and committee meetings. Some 86 per cent said their needs had been met well or very well for evidence generation; 20 per cent indicated a need for even more evidence on risk factors and disease trends and epidemiology. So evidence needs are being better met, but gaps remain.

Using the 35th Global Fund Board meeting held in April 2016 as a reference point, some 90 per cent of African delegates reported having a ‘good understanding’ of the most important issues to the Africa constituencies. However, only 67 per cent reported they had sufficient evidence to ably contribute to discussions occurring during the Global Fund Board meeting and related side meetings with other delegations, constituencies and members of Global Fund leadership; there is a need and a desire for more evidence. In the end, 70 per cent believe that the Africa constituencies were influential during the Board meeting; specific areas of influence cited were related to the allocation methodology, the strategic plan and governance structure.

The survey also asked how technical support affected their personal engagement with the Global Fund board. More than half of respondents said they felt better prepared to execute their responsibilities as a member of the ACB (50 per cent), better understood the complexities in the Global Fund’s policies and operations (80 per cent), witnessed increased participation by African constituents during Board and/or committee meetings (70 per cent), or personally contributed to shaping talking points and/or positions (70 per cent). While no baseline is available for comparison, the open-ended comments were generally positive or indicated a desire for even more evidence and consensus-building activities in the future. We believe these results demonstrate a positive change in the demand for and expectation of evidence use, and that technical support provided by the Bureau has enabled delegates to better use the evidence provided.

5.1 Anecdotal evidence of increased engagement

High-level Global Fund leadership and a senior official from a top donor country expressed pleasure separately at the growth in engagement of the Africa constituencies during the 34th and 35th Board meetings held in late 2015 and early 2016, respectively. In addition, in response to a position paper on proposed changes to the allocation methodology, a senior donor country official commented to the Strategy, Investment and Impact Committee in early 2016:

As we move forward to our final deliberations on the allocation methodology, I am delighted that we have such a clear steer from the African constituencies. The success of the Global Fund in tackling the epidemics will largely depend on the response in Africa, where disease burdens are generally highest, where countries have the least ability to pay, and where there are a number of states affected by conflict and fragility.… To date the voice of the African constituencies has often not come through so strongly and I feel that decisions have often been taken ‘on behalf' of African constituencies rather than by these constituencies – and this, of course, leads to sub-optimal implementation and impact (emphasis added).[10]

In mid-2016, a number of individuals centrally involved in the development of the Bureau since 2012, both donors and African leaders, offered their reflections on the process and progress to date. There was broad agreement that ‘many Global Fund stakeholders have long wanted the African constituencies to have stronger voices commensurate with their large percentages of total Global Fund grants’ (Key informant, interview, July 2016). A former committee leader recalled:

At my first Board Meeting in 2012 [as a member of the ESA delegation, prior to becoming a Board Member], I very clearly remember little was prepared in advance, which was overwhelming considering the volume of content. It so happened that I was asked to sit in the Board Member’s seat in their absence. With last minute preparation, as the ESA delegation present, we were left to say what we agreed was the best position for the constituency. Each of us made the best contributions possible under the circumstances. Much earlier and better structured consultations within the constituency would have permitted a wider and richer representation of the entire constituency rather than one limited to the members of delegation present at that board meeting.

(Key informant, interview, August 2016)

At the November 2016 Board meeting, an African Board member announced to the Board that now, ‘Africa speaks with one voice’, regardless of the ESA or WCA affiliation. A former Communications Focal Point observed:

In the past, the two constituencies were working in silos, and sometimes in opposition to one another. There was no unity of purpose. Recently, interactions between the constituencies have improved, and I’ve seen an increase in engagement and understanding by our Board Members.

(Key informant, interview, August 2016)

A long-time technical manager who supported the development of the governance framework acknowledged the key role especially of ESA leadership in particular who ‘walked the talk’ of the framework, which was crucial to set it in motion.

While all stakeholders acknowledged the constituencies are not there yet in terms of maximising the potential of their influence and participation, they noted improvements – with a few exceptions – in attendance, planning, coordination between constituencies and sub-constituencies, preparation and meeting participation. A former committee chair noted how these changes have manifested, saying, ‘We are working actively ahead of time, participating in committee meetings leading up to Board meetings. There have also been big improvements in the quality of participation.’ However, she cautioned, ‘We still need to get much better – to be much more proactive in setting the agenda in addition to reacting to it’ (Key informant, interview, August 2016). This sentiment was echoed by other leaders. One stakeholder noted that there should be a balance between using the abilities of the current generation while developing the expertise of the new generation.

Enabling factors

6.1 Strong African leadership

No progress would have been possible without leadership from the constituencies that identified the problems and spearheaded the calls for change, with support from the governance team at the Global Fund Secretariat. Sustained, active leadership that values and uses evidence to develop its positions is central to the proposition of the ACB. Driving these efforts was a multinational task force, originally under the vision and leadership of the late Rangarirai Chiteure and past Board chair; past Board Vice-Chair Mphu Ramatlapeng, past Strategy, Investment, and Impact committee Vice-Chair Anita Asiimwe, and other members of the task force who shepherded the process of the formation of the ACB since that time, along with many others. Their collective leadership has been essential to the process.

There has also been a willingness among leadership for the two constituencies to increasingly speak with one voice. In the past, national representatives would at times put the needs of their own country ahead of the best interest of the wider constituency. The nature of the technical assistance provided by a neutral broker lessens the chance for evidence to be used selectively. A broad commitment to consensus building allows for all parties to review the evidence and agree on positions that balance the needs of all countries, in advance of decision-making.

6.2 A supportive network of global partners

The Bill & Melinda Gates Foundation and the United States government provided funds to support the development of a Bureau and the framework. The Global Fund itself has pledged its support for additional resources. Many diverse partners have recognised that a strong, united African voice is crucial to the Global Fund’s success and have demonstrated a willingness to fund the work needed to strengthen and sustain that voice.

Challenges

7.1 The APHRC’s learning curve

Technical expertise and relationships take time to cultivate. When the APHRC was selected to provide technical assistance on behalf of the Bureau in late 2014, its team experienced a steep learning curve related to the complexities of the Global Fund. At the first Board meeting for which it provided technical support, briefs and analysis received a lukewarm reception from Board and committee members. The APHRC had to quickly ramp up the sophistication of its understanding of Global Fund complexities and its particular culture and vocabulary, and also recognise the type of tailored technical support African representatives to the Board appreciated. As the APHRC’s relationships with Board and committee members evolve over time, so does its expertise and depth of understanding about anticipating and addressing their evidence needs. Knowledge brokering is (at least) a two-way process, and is neither ‘push’ nor ‘pull’ alone (Van Kammen et al. 2006).

7.2 Delays in establishing the permanent Bureau

Initially, there were no means, financial or otherwise, to set up the ACB; it was only an idea on paper. Financing the establishment of the ACB, as well as the interim Bureau, took approximately 18 months from the time the framework was signed in early 2013 to the time APHRC started providing technical support in late 2014. Selection of country host for the permanent Bureau was open and transparent; however, countries expressed dissatisfaction with the selection process after it was concluded. Transparency is important, but it is useless unless it is effectively communicated (see more on the challenges of communication below). Establishing the ACB as a legal entity – a process that experienced a year of delays – then enabled the hiring and establishing a physical office space to move forward. Since that time, there have been unanticipated bureaucratic and procedural delays in establishing the permanent legal entity of the ACB that will be housed in Ethiopia, which in turn has caused delays in hiring an executive director to lead the Bureau.

7.3 Intra- and inter-constituency communications

As referenced earlier, the constituencies include 47 countries and many languages. Communication is an ongoing challenge, especially in efforts towards consensus building in very short time frames between the release of committee and Board materials and the meetings themselves. It was a necessity to arrange for translation during formal meetings and briefing materials for delegations, and to earmark funding to make it possible.

There is often only a period of a few days from when all documentation is received – let alone digested and analysed—before the meetings themselves take place. Developing informed consensus positions across languages, time zones and country contexts is next to impossible. Even within each constituency, it is difficult to arrange for feedback and dialogue. Too often, position statements are not truly reflective of the input of all stakeholders. The Bureau uses teleconferences, email, individual phone calls, text messaging and in-person meetings to build consensus over time to develop over-arching positions, rather than case-by-case decision-making. An improved transparent process for soliciting and using country feedback to develop true consensus is imperative for the ACB to take forward in the future.

7.4 Board and committee leadership turnover

The 2013 ACB governance framework brought dramatic improvements in the selection process of its representatives to the Board, and leadership turnover is expected every two years. While the task force has provided some institutional memory in recent years, it is not intended to serve that function. There have been informal discussions that an amendment to the framework could ease leadership transition by staggering when new Board members and alternates start or by extending board member terms from two to three years. Such changes would help mitigate the learning curve of incoming leadership and improve institutional memory. Institutional memory, consensus building and a focus on evidence synthesis and its use are key functions that the ACB will provide. The Africa constituencies are addressing these needs via a physical office with professional staff and dedicated functions. It should be noted that this may not be the only way to do so.

Conclusion

This case study has illustrated the critical role of knowledge brokerage – in this case, synthesis of volumes of information and distilling it into concise and easy to understand formats – in enabling increased use of evidence in decision-making. It was not enough to include the Africa constituencies in the decision-making structures of the Global Fund because without technical support these constituencies were unable to effectively contribute to the Fund’s decisions and programmes. The case study shows that with the technical support, the African constituencies have slowly but steadily requested and used evidence to support their informed participation in Global Fund governance and decision-making. Technical assistance provided to African constituencies helped mobilise knowledge and strengthen their voices in Global Fund decision-making, resulting in meaningful engagement by these constituencies in global decision-making structures. It is hoped that the use of evidence for Global Fund decision-making may have some positive spill-over into other arenas of multilateral or national decision making.

As of late 2016, an executive director has been selected to lead the ACB into its next phase. In addition to continuing and expanding the technical support and consensus building work of the past two years, the ACB will explore opportunities to build alliances with other constituencies outside of Africa. Ultimately, none of this is about a Bureau; it is a means to an end. It is about supporting decision-makers to make use of information provided to them for better and more effective decisions and programmes. More importantly, it is about making the smartest, evidence-informed investments to end HIV/AIDS, tuberculosis and malaria everywhere. In time, it is hoped that a permanent Bureau will help to deliver on this promise.