Principles of Meaningful Involvement of Communities and Civil Society in Global Health Governance
For Global Health Institutions and their key stakeholders:
- Communities and civil society are represented in decision-making structures with a permanent role and equal voting
- Governance support is provided for governance roles and to facilitate broader civil society and community engagement
- Funding is provided for governance roles and to facilitate broader civil society and community engagement
- Civil society and communities design and lead their own open selection processes for their board members and constituencies which reflects the diversity, knowledge and experience of their constituencies and the work of the institution
For civil society and communities:
- Civil society and community representatives are transparent and accountable, seeking to understand and represent the perspectives and priorities of their constituencies
The Principles for the Meaningful Involvement of Communities and Civil Society in Global Health Governance are a best practice guide for all stakeholders in global health. They aim to ensure the expertise and lived experience of civil society and communities is recognised and respected and that their voices and power in decision making processes is formalised to ensure more effective and representative governance structures. Recognising the existence of other important frameworks for meaningful involvement from GIPA1 and MIPA2 to the Denver principles3, these principles are not designed to guide the involvement of communities and civil society across the entire institution or more broadly at regional or national level but rather are intended to focus specifically at the governance level of the specific global health institutions which have been the focus of the principles thus far, acknowledging there is a need to also explore other institutions. The institutions these principles focus on are The Global Fund to Fight AIDS, Tuberculosis and Malaria, Unitaid, The Global Financing Facility (GFF), Stop TB Partnership, Gavi, the Vaccine Alliance and UNAIDS.
The right to participation has long been recognised in international human rights law – linked with the rights: to take part in the conduct of public affairs, to freedom of expression and to access information, peaceful assembly and association4. The principle of participation is also supported by the General Comment on the Right to Health, which requires “the participation of the population in all health-related decision-making at the community, national and international levels5,”. This vision applies across all health areas and all levels of governance and has played an important role in global health responses. For example, the HIV movement made the right to participation and the mantra of ‘nothing about us without us” central from the very beginning: in 1983 the coalition People with AIDS formulated the Denver Principles that required that people living with HIV/AIDS were “involved at every level of decision-making” and “included in all AIDS forums with equal credibility as other participants6.”
The principle of including all relevant stakeholders, including civil society and communities, in decision-making processes has been valued and applied to a strong degree in many of the multi-stakeholder global health institutions created in the early 2000’s – notably the Global Fund, UNAIDS, Unitaid and Gavi. Some global health institutions have embraced civil society and communities into the centre of their decision-making. The working assumption is that when communities and civil society are included meaningfully in governance structures and decision-making, the institution’s strategies and interventions will be better informed, more responsive and ultimately achieve greater health outcomes7.
Unfortunately, there are still many global health institutions and leaders that don’t adequately understand or value the insight and expertise certain stakeholders bring. As a result, some institutional structures and mandates continue to block the inclusion of civil society and communities as equal stakeholders and those with power often ignore or belittle their contributions.
These principles have been developed to help establish global norms and standards to improve the meaningful inclusion and involvement of civil society and communities in global health governance – providing benchmarks for each institution and power-holder to aim for and hold themselves accountable. It is essential that global health governance structures recognise and support the critical importance of country ownership (of which community and civil society play an important role) as well as address the power imbalances often seen between low- and middle-income country stakeholders and high-income country stakeholders in decision-making processes.
These principles have a focus on multi-stakeholder partnerships, where formal representation of civil society and communities in decision-making processes is already built into the mandate and structure of the organisation to some degree8. The principles and their application must not remain static, but rather grow and strengthen over time. This is essential within the ever evolving nature of the global health architecture and the active discussions and questions around the role of multilaterals. We believe these principles will also be a critical contribution to the discussion around how to make the UN system and structure fit for the future. The intention is for the principles to be a living document, open to feedback, review and adaptation as needed. Ongoing feedback and suggestions on how these can be strengthened, particularly from those most marginalised or left behind around the world, is actively encouraged and can be provided via the feedback form on the website.
Principles for multi-stakeholder global health institutions
Communities and civil society are represented in governance and decision-making structures with a permanent role and equal voting
We can learn and build from over twenty years of established norms and success of multi-stakeholder partnership governance models that include seats and votes for civil society and communities. Their experience shows that when all stakeholder groups involved with or affected by an issue have a seat, a voice and a vote in decision-making and oversight bodies: there are more stakeholders invested in its success and help it raise more funds; there is stronger understanding and solidarity built between different stakeholder groups; and the institution comes to better informed decisions that are widely supported and ultimately have more impact. These decisions may take a little more negotiation and time but this is a worthwhile investment if the decisions are more effective and longer lasting.
Civil society and communities are two stakeholder groups that have played a key role in the governance bodies of several institutions. As explained by Rahman et al in ‘The Case for CSO Representation on the Financial Intermediary Fund for PPR’, “CSOs bring essential catalytic technical expertise, agility, accountability, and local context to decisions on health systems and commodities deployment for pandemic prevention, preparedness, and response, evidenced by contributions on ACT-Accelerator and many of its lead agencies9.” In its analysis of the global health architecture, STOPAIDS et al write that “while civil society is typically without financial leverage or enforcement powers, it has a critical role in advocating for sound policies that account for the grassroots realities often overlooked by governmental or corporate decision-makers10.” In Kelley Lee’s paper on the role of civil society in global governance she further describes the crucial accountability role civil society plays, writing that “CSOs are accepted as playing a critical watchdog role, ensuring that formally mandated governmental institutions fulfil their responsibilities appropriately, and keeping a watchful eye on corporate actors exerting undue influence or engaging in health harming activities11”.
Having a permanent role for key civil society and communities in global health institution governance, says STOPAIDS et al, “allows the civil society representatives and their constituencies to conduct long-term planning and advocacy to maximize their impact at the Board level. A permanent role far exceeds a consultative role in that it allows for communication between representatives and the communities they are expected to represent, and vests the civil society representatives with the ability to observe and influence decisions over time, as an institution evolves, rather than only being able to inform discussions or decisions in an ad hoc manner – when the institution picks and chooses. Permanent representation allows for civil society representatives to develop and strengthen their abilities to navigate and influence governance bodies and develop stronger relationships with colleagues facilitating greater understanding and coordination between what are often competing priorities12.”
However, it is not yet universally understood that inclusive decision-making and governance leads to better outcomes and some of those in powerful positions still find many reasons to resist the inclusion of the less powerful – particularly low- and middle-income country governments, civil society and communities. Rahman et al explain that “those who oppose CSO inclusion within governance structures often cite: the need for board agility and efficiency; a perceived lack of technical expertise among civil society; and potential conflict of interest of CSO involvement in decision-making as reasons for exclusion13.” Their paper then goes on to systematically debunk and reject all these rationales and cites evidence from across a number of GHIs to prove the contrary. However, the fact that some of these negative narratives and perceptions of multi-stakeholder governance models and of civil society involvement still linger demonstrates the need for systematic and rigorous study of the impact of these governance models across multiple institutions.
Experience across the existing global health institution inclusive governance models shows that there are 4 key components of the principle that ‘Communities and civil society are represented in governance and decision-making structures with a permanent role and equal voting’:
1.1) Permanent representation (and recognition of the diversity) of both civil society organisations and affected communities
It is crucial to first draw the distinction between civil society and communities and therefore the need for separate seats on the governing bodies and accompanying decision-making spaces across the multi-stakeholder global health institutions.
Civil society organisations (CSOs) or non-governmental organisations (NGOs) are understood as “any non-profit [or] voluntary citizens’ group which is organised on a local, national or international level14.” Recognising the historical and current power imbalance between high income countries/stakeholders and low- and middle-income countries/stakeholders, it is essential we address the representative imbalance by ensuring a specific separate seat for CSOs/NGOs from low- and middle-income countries and one for CSOs/NGOs from high income countries.
There should be a separate seat for affected communities because they bring a distinct perspective that can often be different from that of NGOs – they have lived experience of what it means to be affected by the disease or health issue in question and can give critical guidance about what services are available or not in communities, which services are most effective and what barriers they may face in accessing services. There can also be a power differential between affected communities and NGOs so a separate seat ensures a distinct voice for affected communities. The ‘affected communities’ stakeholder group should be specific to the global health institution in question and will depend on the nature of the organisation’s work. Each institution should coordinate a collective mapping to identify who the grassroots communities are that are most affected by the issue(s) that the institution is seeking to address. For example, for the Global Fund that has a focus on the three diseases of HIV, TB and Malaria, its communities constituency comprises people who are living with or have lived with one of those three diseases.
There is also an active question that must be addressed by each institution across global health with regards to how they ensure the voice and perspective of other key stakeholder groups. Two very important groups are health workers and young people (aged 18-24 years old15). It is not currently common practice within global health governance to include health workers with a separate Board voting seat. However, this is the norm within global education with a governance seat for Teachers in the Global Partnership For Education. Young people are recognised as having a critical input by some global health institutions but the mechanisms vary. GFF has a specific seat for young people and the Global Fund has a Youth Advisory Council.
1.2) Permanent seats in decision-making processes and structures
Permanent seats for both communities and civil society constituencies are critical. They allow representatives and their constituencies to conduct long-term planning and advocacy to maximise their impact at the Board level. A permanent role far exceeds a consultative role in allowing for communication between representatives and the communities they are expected to represent. They provide representatives with the ability to observe and influence decisions over time, as an institution evolves, rather than only being able to inform discussions or decisions in an ad hoc manner – when the institution picks and chooses. Permanent representation also allows for representatives to develop and strengthen their abilities to navigate and influence governance bodies and develop stronger relationships with colleagues facilitating greater understanding and coordination between what are often competing priorities. For example, the NGO Delegation to the Programme Coordinating Board (PCB) of the Joint UN Program on HIV\AIDS (UNAIDS) is unique among other UN bodies in that it is a permanent member of the PCB. Along with Co-Sponsors of UNAIDS, it doesn’t have a voting right but otherwise plays an equal role in decision-making processes of the Board, i.e. contributing to the development of the official documents of UNAIDS.
Building on the permanent inclusion of civil society and communities, it is important to ensure voting power alongside governments and other non-state actors so that all stakeholder groups have a fair ability to influence the decision-making process. Without voting rights, it is impossible to block Board decisions, or to force further discussion when needed. Even in cases where the civil society bloc is unable to muster a veto to a decision, the ability to formally register dissent, through a ‘no’ vote has important political value. Importantly, yet often overlooked, equity in voting rights also promotes collegiality among the representatives of various stakeholder groups and allows civil society and community representatives to approach, dialogue and partner with government and other non-state actor representatives on an equal footing.
1.4) Representation within all decision-making committees (eg audit, finance, risk and strategy) and working groups
Civil society and community representatives must also be present in all other governing body committees or working groups. This is particularly important in relation to committees or working groups that are making or recommending decisions for the governing body to approve. The inclusion of civil society and communities in these bodies should be from their inception through to their role in the monitoring and evaluation of decisions to ensure accountability to the constituencies they represent. Civil society and community representatives should be invited to participate in each working group, at every meeting, and should be given an equal voice to other members in these discussions. They should also be given equal opportunity and consideration to apply for leadership roles of these committees.
Examples of Principle 1:
- Since its founding, the Global Fund has maintained a 50-50 division of Board votes between donors and implementers through its various constituencies with permanent seats for three civil society constituencies, the Communities Living with HIV and affected by Tuberculosis and Malaria Delegation, the Developed Country NGO Delegation and the Developing Country NGO Delegation. A two-thirds majority vote is needed on both the donor and implementer side to pass a decision, and each of the three civil society constituencies has a vote. This bloc of three civil society delegations are one vote shy of mobilising a blocking minority (veto) of any decision to be taken by the Board and, while rarely ever used, it means that the voice of civil society is strongly heard and compromise more eagerly sought where there are areas of significant disagreement.
- Meanwhile, at the Stop TB Partnership there are 7 permanent seats with one rotating seat making the affected communities the largest representation at the board leading to an elevated voice of communities at the board which is often not seen in other GHI boards. With two seats for affected communities, two seats for key and vulnerable populations and one rotating as well as two seats for NGO from developing countries and NGOs from developed countries, the Stop TB Board has a strong balance of civil society representation, reflecting the diverse experience these different constituencies bring to the decision making processes of the institution.
- The Global Financing Facility represents an example of inclusion of young people and provides an opportunity for other constituencies to learn from and improve their own engagement with youth representatives. At the Global Financing Facility Investors Group, (the GFF’s Board), besides the four seats for civil society (two principle and two alternates), there are also two separate seats for youth representatives (one principle and one alternate) with equal voting power. This is an example of good practice as, given the GFF works on reproductive, maternal, newborn, child and adolescent health and nutrition, it is important for it to have this strong focus on youth. Moreover, one of the representatives of the youth constituency currently co-chairs the Investors’ Group SRHR Technical Advisory Group, which provides recommendations on how to further strengthen the collaboration on SRHR with a specific focus on adolescents. Having a seat for youth representatives is currently not common practice for GHIs but would be a strong addition to the governing bodies to ensure that youth voices are effectively represented.
- In ACT-A, there was civil society and community representation across each ACT-A pillar, in each of the technical work streams for each ACT-A pillar, and at an overarching level in the Facilitation Council.
- In the UNAIDS PCB, the NGO Delegation represents five geographic regions: Africa, Asia & the Pacific, Europe, Latin America, North America & the Caribbean. The Delegation is composed of five members and five alternates. It takes part in different working groups of UNAIDS, as well as having its own internal working groups on different issues pertaining to UNAIDS functioning. In addition, it leads with a yearly NGO Report that is an official document of UNAIDS’ board.
Governance Support is provided for governance roles and to facilitate broader civil society and community engagement
2.1) Establish a governance support mechanism based within the governing body
This body supports all governing body representatives to ensure due notice and clarity of governing processes and timely delivery of governance information to representatives. Civil society and community representatives should be notified well in advance of when they will receive documents for feedback with a clear deadline that allows enough time to consult with broader civil society and communities. Where information is to be embargoed, a clear communication should be provided including reason and for how long.
2.2) Establish civil society and community engagement mechanism(s) / constituency(ies) around the civil society and community Board Members
In global health multilaterals such as the Global Fund, UNAIDS, UNITAID and GAVI, this often takes the form of a stakeholder constituency / delegation for civil society or community Board members with a communications focal point responsible for logistically supporting the Board members and the support of the constituency members. A constituency approach in governance structures works well because this avoids individual institutions speaking solely for their own interests. Representatives should be supported in their roles with sufficient handover periods with previous representatives and the governing body to ensure continuity and effective representation of their constituency. Each global health institution should also have a staff member who has named job responsibility for ensuring meaningful involvement of and engagement with civil society and community representatives.
Young people should be supported through capacity building, such as mentorship processes to foster meaningful engagement and representation in decision-making processes. The constituency representatives must ensure the wider engagement of young people and must be supported to create structures that enable this. One example could be the establishment of a Youth Advisory Council. Y+ Global’s Ethical Engagement Guidelines will be an important tool to refer to when strengthening this among constituencies. The need for support from Key Population networks should also be recognised given priority populations often lack access to global funding and support for meaningful involvement in decision-making spaces.
Moreover, support should include a recognition of the numerous barriers which, at present, prevent meaningful engagement and access to these decision making spaces and which prevent meaningful civil society and community participation in discussions. These obstacles include, but are not limited to; language barriers, connectivity and data issues, timing of meetings, access to information and documents. Support mechanisms within the governing body and civil society and community engagement mechanisms should address these barriers where feasible to ensure civil society reps from across the world are given opportunities to input and engage with these processes and their engagement.
Examples of Principle 2:
- Building on leadership shown in the early months by generating civil society and community engagement and representation in the Access to COVID-19 Tools Accelerator (ACT-A), Global Fund Advocates Network (GFAN), WACI Health and STOPAIDS established the Platform for Community and Civil Society Representatives in ACT-A (the Platform) to convene and support the identified civil society and community representatives in ACT-A and to provide a platform for engagement with broader civil society and communities. A critical principle applied to the facilitation of this platform is that it is hosted by institutions from both the global north and global south. The platform has performed the following roles:
- Facilitating selection processes to identify and appoint the interim and then full-time representatives for each of the ACT-A Pillars and the Facilitation Council. Civil society and community representatives have been appointed to the diagnostics, therapeutics and vaccines pillars of ACT-A, with interim representatives to the health systems connector and Facilitation Council. The selection committees were facilitated by the Platform but once the Platform was up and running, existing C/CSO reps were in the selection panel to review and make decisions.
- Facilitating an email listserv and virtual meetings every two weeks for all the civil society and community representatives across the ACT-A to collaborate and share intel.
- Facilitating an email listserv and a virtual meeting every two weeks for the civil society and community representatives for each of the ACT-A Pillars to discuss pillar-specific business. These listservs and calls are co-ordinated by Pillar Focal Points.
- Facilitating a website, a listserv and broadcast calls every two months with broader civil society and communities interested in the work of the ACT-A and the civil society and community representatives to enable consultation and information sharing.
This platform is managed without any external funding and has put a limit and strain on the support they have been able to provide.
- At Stop TB Partnership, there are virtual regular updates where the secretariat updates the board and constituency members. The secretariat also offers training for new civil society and community board members to ensure they are fully equipped with the information needed to effectively participate at board level.
- GAVI’s Civil Society Steering Committee is made up of a group of 20 civil society organisations which each bring their unique and valuable perspectives, expertise and experience to the immunisation work of the GAVI Alliance. Although the GAVI board has only one civil society constituency, the structure of the steering committee should be commended as a good mechanism for civil society involvement.
- The Communication and Consultation Facility (CCF) provides independent technical and administrative support to the UNAIDS PCB NGO delegation. The UNAIDS Secretariat funds the CCF, which is independently hosted on two-year contract terms by recruited NGOs. The implementation of activities, performance management, and overall responsibility for achieving deliverables belong to the Delegation.
Funding is provided for governance roles and to facilitate broader civil society and community engagement
Financial support is essential for civil society and community representatives to effectively and consistently represent the group they have been chosen to represent. Representatives are often responsible for representing expansive constituencies and therefore require financial resources to support the costs of communicating with, and seeking the input and approval of their global constituencies, to ensure they are legitimate and effective representatives. Global health institutions must provide adequate resourcing to facilitate the participation of civil society and community representation and for a body to effectively convene the representatives and facilitate the inclusion of, and exchange with, broader community and civil society voices.
3.1) Recognising and addressing the resource gap for Low or Middle-Income (LMIC) communities and civil society
Civil society and community representatives from Low or Middle-Income Countries (LMIC) do not always have the same level of financial and institutional support with their colleagues from the global north, which creates an imbalance of power and capacity to engage. This can result in low- and middle-income country board members not being able to dedicate the same time as better resourced stakeholders in the global north. To address this issue, there must first be an acknowledgement that, due to financial constraints, some LMIC board members may face challenges in dedicating the same amount of time and effort as their counterparts from developed countries and, until additional resources are made available, there should be more adjustment in expectations regarding their commitment. To address the issue of wage disparity between civil society and community representatives from different regions, the governing board should consider implementing a compensation structure that ensures fair and equitable treatment for board members, regardless of their geographical location. Further steps to rectify the existing power imbalance can be promoted by providing necessary support and incentives for board members from LMICs. This should involve exploring funding options, partnerships, as well as capacity-building initiatives. All this is essential to promote the active engagement and representation of civil society and community representatives from the global south in decision-making processes, acknowledging their unique perspectives and challenges.
3.2) Ensure an annual budget for each constituency
An annual budget for each constituency, provided by the governing body, is essential. This budget is particularly important where the representative in question may not have sufficient resources at their disposal to cover this otherwise.This budget covers annual activities, including research, planning and consultation meetings between the Board member and the constituency as well as expenses for the Board members and/or some salary contribution for the constituency’s communications focal point, (if any). The budget should also include some funding that will allow the constituency to engage, consult and gather information at country level – facilitating the gathering of real-time community data through local-level community-led monitoring mechanisms. This budget should be in addition to the cost of governance-related travelling for civil society and communities constituencies including flight, accommodation, per diem and visa costs (any invitation to attend in-person meetings should include the possibility of expenses being covered so that civil society or communities are not excluded from joining in-person). The budget allocated to support civil society and community participation in decision-making spaces should also recognise the structural barrier of the digital divide. Consequently, it should ensure support for data bundles and the necessary technologies required to participate in online meetings, given the ever increasing shift to online meetings. Failure to recognise the digital divide for the most marginalised or resource constrained representatives when calculating the necessary financial support will result in increasingly weaker involvement.
Examples of Principle 3:
- At Unitaid, the Finance and Accountability Committee approves an annual budget to both the NGO and Communities Delegations. These grants are managed by the host institutions of the delegations. This funding covers a Focal Point to support the delegation, employed by the host institution. The grant also covers online costs (such as webinar and website hosting), travel costs to allow delegation members to attend Board meetings and an annual evaluation of the performance of the Board Members to ensure they are accountable to the broader constituency. The delegation also receives an additional grant to cover the travel costs for the Board Member, Alternate Board and Focal Point to attend all Board and Committee meetings. The budget also provides the Board Member and Alternate Board member with a technology and communications stipend to support technology related costs to help address the digital divide and provide some compensation in the otherwise largely unfunded roles.
- Through targeted advocacy, the civil society and youth constituency of the Global Financing Facility (GFF) managed to get a USD 5 million grant from the GFF, as part of the GFF’s Civil Society and Youth Engagement Strategy. An NGO host institution was selected by the GFF to manage these funds, which are meant to facilitate civil society engagement and capacity strengthening. The NGO host institution is responsible for facilitating consultations between the delegation and the broader civil society and youth constituency ahead of the GFF Investors Group meetings and for organising technical assistance to CSOs. On top of that, the GFF Secretariat covers all the costs (travel, accommodation, daily expenses) for the participation of the civil society and youth delegates at the GFF’s Investors Group meetings, and facilitates all the travel arrangements.
Civil society and communities design and lead their own open selection processes for Board members and constituency that reflects the diversity, knowledge and experience of their constituencies and the work of the institution.
Within a multi-stakeholder model of governance, it is essential that all stakeholders are asked to identify their own representatives who they feel can best represent them and their interests within the bounds of the common core skill and experience criteria set for all Board Members. For example, this means that if you ask a government to choose and send their own representative(s) for the Board then you must do the same for communities and civil society.
The selection process for civil society and community governance representatives should be designed and led by civil society and communities themselves. Where there are separate Board seats for civil society and communities, the relevant civil society or community group represented by the Board seat should lead the selection process for their Board representative. Those leading the selection process should also agree on what should be the term (time period, e.g. two years) of each Board member to serve on the Board before the need for reselection.
When a standard open selection process is established it should facilitate more accessible and open processes that encourage as many as possible to apply, particularly from typically underrepresented groups. The selection processes itself should also be externally reviewed to ensure the process was conducted appropriately and to encourage transparency and trust across the constituencies. Establishment and implementation of conflict of interest policies within the selection process are important to ensure that there is full transparency in the process and any conflicts of interest can be addressed appropriately. This review can then support in providing valuable lessons to continually improve these processes to enable more diverse and inclusive representation amongst the constituencies.
Furthermore, steps should be taken to mitigate elite recycling of the representatives themselves; expert and institutional knowledge needs to be weighted with fresh perspectives.
4.1) The selection process should reflect the diversity, knowledge and experience of their constituencies and the work of the institution.
The diversity of civil society and communities should also be reflected in the selection processes and outcomes. Policies and rules for the recruitment and selection of civil society and community representatives should ensure the involvement of LMICs, with a geographical balance and to prevent the imbalance of power and resources from global north civil society representatives dominating global health spaces. This should include representatives of civil society and communities originating from and living in LMICs and most affected by the health issues relevant to the institution (a distinction should be made between institutions and individuals from international, northern NGOs based in LMICs). Moreover the selection process should recognise the importance of the inclusion of women, and gender expansive persons, in decision making spaces to ensure a greater gender balance amongst civil society and community representatives with global health governance.
It is appropriate for a global health initiative to set skill and expertise criteria and standards for good governance for the participation of all members in the governance body but these must be applicable to all stakeholder representatives and not be altered or added to for one member only. These rules must be equitably applicable, unless has been agreed with the stakeholder group in question.
The constituencies should ensure representation across all different diseases and health issues focused on by the Institution in question to ensure inclusion of lived experience and cross-cutting disease representation. The civil society and community representatives should be involved as full members with technical expertise to be valued, with the same rights and prerogatives as the other constituents represented in the governance mechanism.
Evidently the elected governance representative(s) cannot fully represent the diversity of their entire constituencies and therefore the selection processes (as outlined in Principle 3) for advisors and other constituency members should equally ensure balance across the regions the constituency seeks to represent. This second-line leadership should be supported, resourced and strengthened to provide a more robust support network of representatives to contribute to the work of the constituency. If there is more than one civil society or community representative, it is important to ensure civil society institutions in different parts of the world are represented, both across geographic regions and also across country economic classification – with representation across low-, middle- and high-income countries. Mechanisms and resources for consultation and accountability should be provided. The terms of reference, recruitment and election of civil society and community representatives should clearly articulate the mechanisms necessary for effective and transparent sectoral representation.
It is important to note that professional associations and the private sector do not count as civil society. Academic representatives can sometimes be considered as civil society but generally only if they have strong connections and close working relationships with civil society and community networks. All of these issues should be clearly defined in the institution’s governance policies and rules.
4.2) Identify appropriate organisations to run selection processes and support interim Board Members in newly established institutions.
If a global institution board has been newly created, the governing institution secretariat should identify (ideally through an open selection process, see below) an independent civil society or community organisation (or group of institutions) to help facilitate the process of selection of interim or permanent (as appropriate) civil society and community representatives through an open nomination process. It can be particularly effective to have a partnership of different types of institutions from both low/middle income countries and high-income countries or covering different thematic areas. The institutions chosen should ideally have experience of running civil society and community selection processes previously and/or demonstrate a clear understanding and commitment to the key principles set out in this document. They must also have the backing of the majority of (or at minimum not be controversial among) civil society and communities engaged with the governing body. If the governing body has funds available to support civil society engagement in the governing body, the civil society institution running the process would ideally be identified through an open and transparent RFP process and receive some contracted funds from the governing body to run the selection process. The civil society institutions running the selection processes should ideally remain neutral in the selection process and not put their own staff forward to be a board member to avoid real or perceived conflict of interest. If they do put a staff member forward, clear mechanisms to manage the conflict of interest should be established.
Once the interim and then 1st permanent civil society/community Board reps have been selected for a global institution, a key focus should be the formal establishment of funded civil society and/or community constituencies to support those board members (Principle 2). These constituencies, once established, would then have ongoing responsibility to run the selection processes for their future representatives, utilising the same principles of open and fair selection processes.
Examples of Principle 4:
These examples serve to highlight the important distinctions between civil society organisations in different parts of the world (and the particular perspectives they bring) and, in particular, the critical importance of recognizing the right to self-representation and distinct voice of communities affected by the health issues dealt with by a particular global health institution.
- For the ACT-A, The Global Fund and Unitaid invited the civil society and community constituencies to their boards to run a process to identify interim representatives to the diagnostics and therapeutics pillars. GFAN, STOPAIDS and Waci Health supported the civil society and community constituencies to the boards of the co-hosting agencies to advocate and secure civil society and community representation to the vaccines pillar (COVAX), health systems and response connector, and the Facilitation council and its working groups.
- At GFF, the civil society representatives are also selected to ensure gender and diversity balance as well as balance between anglophone and francophone representatives.
- The composition of the UNAIDS PCB NGO Delegation changes every year. The delegates serve a term of two years, with a possible extension to three, based on the results of their performance assessment. The NGO Delegation’s recruitment is guided by ECOSOC resolution 1995/2, which states that ‘The selection of the five nongovernmental organizations will be determined by the NGOs themselves from among those either in consultative status with ECOSOC or in relationship with one of the cosponsoring organizations or on the roster of NGOs dealing with matters pertaining to HIV/AIDS. The PCB shall formally approve the NGOs nominated.’ Applying NGOs are shortlisted by all members of the NGO Delegation. A selection panel consisting of an NGO Delegate from the same region as the vacant seat, an NGO Delegate from any other region, plus a civil society representative from the same region as the vacant seat interviews the shortlisted candidates. Based on the outcomes of these interviews, the full delegation chooses the most suitable candidate to fill the vacant seat on the NGO Delegation.
Principle for Community and Civil Society Constituencies
Civil society and community representatives are transparent and accountable, seeking to understand and represent the perspectives and priorities of their constituencies
Firstly, in recognising the apparent inequity in the capacity of some community and civil society members to engage, it is important to first look at how to make these processes more open and accessible. This is the first step in addressing the issue of the same institutions engaging and holding representative roles due to others lacking the same capacity which larger institutions can allow for. Efforts to ensure more diverse representation includes; budget to support this outreach and engagement with less represented groups, intentional language in Terms of Reference which actively encourages those from LMICs to apply and support from constituency members outside the core leadership to support with this outreach.
Each civil society or community representative should seek to understand and represent the perspectives and priorities of the group they have been chosen to represent. If it is a Board role to represent civil society or communities, it is very important that the Board member role criteria makes it explicit that that person is expected to consult with broader civil society and to actively seek to represent the views of civil society beyond their own institution or personal opinion. At minimum this requires the representative to have good existing connections to and relationships with civil society and community groups working on the topic of focus of the governing body and an expressed and manifested commitment to utilise, and continue to expand, these connections to consult and keep people up-to-date while in the representative role. This should also include the constituencies supporting and engaging community-led monitoring mechanisms at local and national level to gather real-time information about service experiences and channel this information directly to civil society and community Board members who can then ensure this informs governance discussions and decisions.
Furthemore, the representative must be fully transparent in their role in making public any perceived or potential conflicts of interest to the group they seek to represent as well as the global health institution itself where necessary. This principle of transparency should also be embodied in how the civil society and community representatives feedback to their constituencies. There should be a clear, transparent and robust feedback mechanism for each constituency to ensure that the elected representatives are able to proactively share their feedback with an internal grievance policy to support the resolution of any internal conflicts. Accountability mechanisms should be put in place to allow for regular reporting back to civil society and communities. Constituency members should be made aware of their right to participate across the various governance processes. This should be coordinated by the core leadership to ensure all input is adequately documented and processed to consequently influence the constituencies’ feedback to the Board. Reporting back mechanisms should, at a minimum, include a consultation ahead of board and committee meetings (or any other major governance discussion) as well as debrief calls to ensure the constituency is well informed and able to input into these discussions. All updates should be clear and accessible, always with the opportunities to provide feedback to ensure the constituencies are well positioned to report back to their institutions or communities, the format of the feedback should be pre-defined and agreed on by the civil society and community constituencies themselves. It is important to ensure timely access to information whilst providing these regular opportunities for civil society and communities to share priorities, concerns and feedback to their board representatives to support meaningful involvement across the constituency. This is also best practice for the global health institutions to ensure constituencies adequate time for review. There should be transparency in the sharing of board documents and constituencies should have concrete conflict of interest policies in place to support this. Constituencies should also each have their own internal grievance/disciplinary policies and processes in place to address and appropriately resolve any serious concerns or issues that are raised in a fair way for all parties concerned.
Finally, in their role as board members the civil society and community representatives should not feel obligated to represent the Board or global health institution itself. There should be a clear distinction of the role of these seats on the board – that is to represent the views, expertise and experience of their constituency. This is crucial for the civil society and community constituencies to maintain an analytical and critical voice in decision making spaces.
- To ensure accountability, within the NGO and community delegations at Unitaid, regular consultations take place between the board members, focal points, key advisors and the main delegations of each constituency. The NGO Delegation also undertakes an annual evaluation led by an external consultant to review the performance of the Board Member, Alternate Board Member and Liaison Officer as well as how the delegation is operating as a whole. This process includes getting feedback from delegation members on the strength of their consultations with their constituency. The evaluation is funded as part of the delegation’s grant. The NGO delegation has also actively expanded its membership base through targeted outreach to NGOs based in low and middle income countries in an effort to ensure the delegation is more representative and to prevent the perpetual dominance of global North NGOs. This process is ongoing and includes the need to reform the selection process of Board members themselves to ensure more balanced geographical representation of the leadership roles.
- At the GFF, there are online consultations with the civil society and youth constituency and the representatives, ahead of the Investors Group meetings, in order to consolidate the positions of the constituency.
- At the STOP TB Partnership board there regular orientation, training and capacity building sessions are organised for newly elected members and board members on policy and updates of ongoing and upcoming events.
- At the UNAIDS PCB NGO Delegation, there is a mentoring process for incoming delegates to make sure that they are able to participate in their full capacity as representatives of civil society and regional delegates. It requires familiarisation with the PCB processes, understanding the dynamics of internal NGO Delegation work, and adjustment to the workload to ensure timely delivery of expected tasks during and in-between PCB meetings. To that end, there is an internal Orientation and Accountability working group that leads on these processes, as well as Delegates’ Manual and Code of Conduct.
- https://data.unaids.org/pub/briefingnote/2007/jc1299_policy_brief_gipa.pdf ↩︎
- http://catalogue.safaids.net/sites/default/files/publications/MIPA_Brochure.pdf ↩︎
- https://data.unaids.org/pub/externaldocument/2007/gipa1983denverprinciples_en.pdf ↩︎
- https://resourcecentre.savethechildren.net/pdf/Civil-Society-in-PPPR-Governance-Research-Report.pdf ↩︎
- OHCHR. CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12). para 11. https://www.refworld.org/pdfid/4538838d0.pdf ↩︎
- Advisory Committee of the People with AIDS. The Denver Principles. Denver: People with AIDS; 1983.
- UNAIDS and Stop AIDS Alliance (2015), Communities Deliver: the critical role of communities in reaching global targets to end the AIDS epidemic.
http://www.unaids.org/en/resources/ documents/2015/JC2725_communities_deliver ↩︎
- https://www.kff.org/global-health-policy/issue-brief/civil-society-inclusion-in-a-new-financial-intermediary-fund-lessons-from-current-multilateral-initiatives/ ↩︎
- https://covid19advocacy.org/wp-content/uploads/2022/06/CSO-White-Paper-The-Case-for-Inclusion-in-FIF-Governance.pdf ↩︎
- HIV, UHC, and the future of the global health architecture’, 2018, STOPAIDS, CSSN, Pitch, AIDS Fonds, Frontline AIDS, p.35:
- Lee, K (2010), Civil Society Organizations and the Functions of Global Health Governance: What Role within Intergovernmental Organizations? Global Health Governance, 3(2).
- HIV, UHC, and the future of the global health architecture’, 2018, STOPAIDS, CSSN, Pitch, AIDS Fonds, Frontline AIDS, p.37 ↩︎
- Rahman et al, CSO White Paper The Case for Inclusion in FIF Governance, 2022. https://covid19advocacy.org/wp-content/uploads/2022/06/CSO-White-Paper-The-Case-for-Inclusion-in-FIF-Governance.pdf ↩︎
- https://www.un.org/en/civil-society/page/about-us ↩︎
- Y+ Global’s ‘Guideline on the Meaningful and Ethical Engagement of young people living with HIV in the HIV response’ ↩︎