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Section: Regional
March 30, 2005

An Open Letter to Dr. Michel Kaztchkine, Director of the Global Fund

October 23, 2007

Dr. Michel Kazatchkine


The Global Fund for AIDS, Tuberculosis and Malaria


Dear Dr Kazatchkine:

First of all, I would like to thank you for the invitation to attend the GFATM Latin American/Caribbean (LAC) Regional Forum in Bogotá earlier this month. 

The Agua Buena Human Rights Association has prioritized our work in the past five years in order to focus on rapid and effective implementation of Global Fund projects in our target countries, especially where access to life saving medications is a critical issue. 

The situation seems to have improved considerably during this time and we know that thousands of people are receiving anti-retrovirals with GFATM support in the poorest countries in Latin America and the Caribbean (LAC).  But we have still have some issues for you which I would like to summarize as briefly as possible (given that these are often complex issues) in this letter. 

I would like to add, Dr. Kazachkine, that I was impressed with your willingness to reach out to Civil Society at the Forum held in Bogota.  But in Bogota, different people from various sectors also discussed “in the hallways” the “limits” of what the Secretariat can and cannot do.   In the following letter, some of the issues I am referring to in terms of potential actions, perhaps go beyond what seem to have been the normal and accepted limits of Global Fund policies as implemented by the Secretariat.  But I am an optimist, and I believe that it is always worth a try to see what can be changed, even within the framework of the “country driven” philosophy of the Fund, and especially when some policies can inadvertently have a detrimental effect on PLWA whose lives are in jeopardy.

Perhaps under your leadership, and with your commitment to the importance of ARV access and comprehensive care, you will find areas during your term in office  where some of these  limits can be pushed, in order to improve not just the indicators used by the GFATM but also, the fundamental impact of projects on target populations and their survival.  This is my hope in sending this letter.

The Global Fund and Sustainability of Treatment in Lower Middle Income Countries

A major dilemma in the Latin American/Caribbean  region has to do with sustainability of treatment, if and when Global Fund projects are no longer available to the region.   On the one hand we understand the importance of lobbying national governments to guarantee treatment in the public sector. The Global Fund cannot continue to provide treatment forever.   On the other hand, some countries, including Jamaica, Guatemala, Belize,  Honduras, the Dominican Republic, Ecuador, Paraguay,  El Salvador, Bolivia,  and Nicaragua now depend almost entirely on the GFATM for treatment access. Peru , through an innovative project was able to move from depending on the GFATM funds to nearly 100 percent coverage in the public sector provided by the Health Ministry.  Yet even Peruvian activists are worried about their government’s ability to maintain this commitment at this point, given that over 7,000 people are now on treatment in the public sector.    

The high cost of 2nd line medications, and the even higher cost of newer medications which may soon be on the market are still a significant and real obstacle in the poorest countries in Latin America and the Caribbean. Many of these countries are ranked below 100 on the latest UNDP Human Development Index, (HDI) and none of the above countries are ranked above 80.  (See Table 1 Below)    It is our hope that the Global Fund will continue to prioritize treatment access in the region’s poorest countries, and will continue to develop approaches that are highly sensitive to the importance of guaranteeing access to treatment, while activists and other “key actors”  continue to pressure national governments to assume their responsibilities.   

Table One: Amount of  5 Year GFATM projects, and UNDP HDI of selected countries in LAC


5 Year Approved
Amount (millons)


2006 HDI Index









El Salvador




























República Dominicana




Problems related to Principal Recipients

Individual Principal Recipients continue to act capriciously in some cases with regard to life-saving medications.  For example, we have been told that when World Vision, PR for Guatemala, reached its “indicator” of approximately 600 people on treatment for the whole year, it was still early in the year, in early May.   Yet we know that what World Vision is paying for medications is far less than what would have been the anticipated budget when the project was submitted in 2003.  So why is the excess money not being used to place additional people on treatment, even if this would be beyond what their indicator requires of them?  What is the position of the Global Fund about changing indicators as new necessities develop?

As a second example of life threatening rigidity (which, unfortunately, seems to also conform to Global Fund expectations) in project implementation, World Vision representative Dr. Mirna Barahona  told us in a letter we received on October 3rd,  (copy on file)  that the Tenofovir that it is purchasing at this moment, cannot be used for any PLWA who began treatment in the first stage of the GFATM project and has resistance or clinical failure, but only for PLWA who develop resistance in the second stage of the project, since the budget for this purchase is related to the second stage.   Yet there is no other source of Tenofovir in Guatemala , so this decision seems tragic and unnecessary. Clearly, those PLWA  most likely to need Tenofovir at this time are people who would have begun treatment during the first phase of the project.

Our most recent information from a physician indicates that 3 people are dying each day in just one of Guatemala ’s several main hospitals, and a total of 8 people per day throughout the country. This is a  total of 3,000 per year, in a country where the $40.9 million Global Fund project was to supposed to have a significant impact on HIV mortality.       It is not clear where the responsibility of World Vision ends, and that of the National Government begins, but it is clear that there needs to be an evaluation between all key actors as to why so many people continue to die of AIDS in Guatemala, when so much money is available,--- and that World Vision must participate in such an evaluation, and not simply continue to insist, as they have  in communications with us in the past, that they are fulfilling their indicators.  We have chosen World Vision as example, but similar situations exist in many Principal Recipients that we have encountered.  

A related and complex problem has to do with the changing, but unanticipated needs of the PLWA population during a given phase of the project. In some cases, the numbers of PLWA needing treatment have grown faster than were projected during either Phase I or Phase II of a project.  For example, in the Dominican Republic , an estimated 6.500 people now have access to ARV’s as a result of funds provided by the GFATM (five year project total is $48.5 millon).  At the same time the mortality rate is not diminishing and an estimated 5,000 people died of AIDS last year, meaning that as many 8,000 to 10,000 people probably need treatment now. Yet the budgets and project parameters are basically set, and there is not much flexibility built into the GFATM to accommodate changing panoramas in the epidemic, once a project is approved.    I am not sure what can be done about this but it is problem that the GFATM should consider in terms of its guidelines regarding budgets assigned for ARVs.

In Guatemala it is evident that World Vision, in their project application has underestimated the number of new PLWA who would require treatment each year, as well as the number of people who would need salvage therapy. It is a fact that in both Guatemala and the Dominican Republic , National Governments are not committing necessary resources in order to complement funds provided by the GFATM.   Yet, and somewhat paradoxically the arrival of the GFATM  in many countries has caused a certain level of complacency in affected  communities in terms of their advocacy efforts directed at  their own governments.  But, after the fact, many have discovered the GFATM  projects leave significant gaps in provision of urgent medical services, whether it be 2nd line medications, lack of reactives so that CD4 and Viral Load tests can be completed in a timely fashion, lack of medications for Opportunistic Infections, etc. 

Similarly, constantly changing prices affect ARV roll-out costs, but “indicators” for access are sometimes determined several years ahead of time.     While costs of first line treatment have diminished since some projects were approved, more and more people now need 2nd line treatments, and this need has not been anticipated in many GFATM projects.   Honduras is an example where for much of 2006 and even up to the present there has not been availability of 2nd line protease inhibitors, especially Kaletra, so many people have died because neither the PR nor the National AIDS program could provide 2nd line treatment.  Now, since the price has dropped from up  $5,000 per year to around $550 per year for a generic version, we are seeing that Honduras is now purchasing and utilizing Kaletra, but there are still gaps in coverage.  Similarly so called “third line” treatments known as integrase inhibitors will soon be registered in LAC (the Merck product called Isentress is already available in Mexico ) but the prices of these medications are likely to be even higher than Kaletra. Yet for those who fail 2nd line in the next few years, integrase inhibitors may offer the best salvage therapy option.    

With respect to prevention of Mother to Child Transmission, (PMTCT), PAHO has reported in its latest regional summary that the number of pregnant mothers who actually receive ARV’s for PMTCT are as follows in the countries referred to in this letter:

Dominican Republic: 27 percent

Ecuador:                    22 percent

El Salvador:               18 percent

Guatemala:                 10 percent

Honduras:                  12 percent

Peru                               9 percent

For other LAC countries,  the numbers are dramatically different such as Argentina (87%), Costa Rica (100%), Chile (100%) and Cuba (98%).  

Once again, given the resources provided the GFATM for the above listed countries, one would hope that this critical area would be receiving more attention, and that impact of the projects would be apparent in terms of these highly preventable infections. The statistics referred to may not directly be a result of failure of a GFATM project per se, but they certainly reflect a need for the GFATM to participate in a holistic assessment of how resource allocation is coordinated between CCMs, PRs, and National AIDS programs.

When National Government Policies Dominate CCM’s  And ‘Override’  Obvious Best Practice

In India , where I spent six weeks last year, there are NO 2nd line medications available, and this is a “lethal decision” taken by Mrs Sujatha Rao, the Director of the National AIDS program.  Yet the funds for these medications are, at least theoretically, available through a variety of sources, including a multi-million dollar Round Four grant that was approved for treatment access, but did not specifically mention 2nd line medications.   About 85% of this money was still untouched when I was in India .  But Mrs. Rao’s decision silences the voices of poor, humble and sick Indian PLWA who have been advocating and demonstrating for 2nd line medications for over a year.   NACO is part of the CCM, and the poorest of PLWA are represented with a small minority of the votes and NACO has decided that those Indian  PLWA who need 2nd line are expendable. If the Global Fund portfolio managers were able and willing to advise the CCM on the use of millions of dollars of funds still untouched, then the panorama might be very different for the hundreds who now die each month for lack of 2nd line treatment.  

After I spoke about this situation  with Dr. Richard Feacham, your  predecessor, last December, I received a letter from the India Portfolio Manager Mr. Tafiqur Rahman.  Mr.  Rahman’s letter to me, as well our response to his letter can be found on our website at:   Unfortunately, as the reply to Rahman indicates,  it was my  impression that Mr. Rahman was more interested at that time in ‘defending’ the decision to not use 2nd line medications than to seek a pro-active solution within the parameters of the Global Fund’s range of possible procedures.  Even now, nearly a year later, what has the Global Fund done to try to push the CCM (within the limits of its parameters)  for a decision regarding delivery of 2nd line treatment using funds that are clearly available?  

I personally am not sure how the “country driven” philosophy relates to “obvious best practice” when it comes to issues related to life and death of populations who could potentially benefit from GFATM funds, but I hope that this issue will continue to be at the forefront of your own concerns as Executive Director.   The Global Fund message continues to be somewhat “mixed” with respect to Civil Society activists focused on social justice who are striving for universal access.  On the one hand, the Global Fund is constantly promoting the “role” and importance of Civil Society, on the other hand “country”, as used in the phrase “country driven” also implies the often dominant presence of National Governments, as in the case of India and many others, which frequently do not share the same concerns as Civil Society activists when it comes to the survival of a nation’s poorest and most vulnerable individuals. In many cases, its not just government as such, but a lethal combination of  Principal Recipients and CCM’s, who are rigidly focused on “indicators” instead of on human lives.     According to a report  from  the Fund itself  “The sustainability of the Global Fund depends upon whether its structures and processes fully involve Civil Society, whether the voices of Civil Society are translated into action and whether the participation of civil society ensures that limited resources are rapidly distributed to the areas and communities that need them the most.” (An Evolving Partnership: The Global Fund and Civil Society in the Fight Against AIDS, Tuberculosis and Malaria, P9)

CCM  Composition with Respect to those most likely to Die of AIDS

With respect to CCM composition, it is clear that several major problems still exist.  Although there are “more” Civil Society representatives on CCMs, we have not always seen that this guarantees truly meaningful participation of the most marginalized populations of Civil Society. These populations include, but are not limited to, men who have sex with men, sex workers, transgendered individuals, ethnic minorities such as Haitians in the Dominican Republic, indigenous populations in the Guatemalan Highlands, the most isolated Garifuna communities in Honduras, as well as other examples.  In many of these communities, people are still dying for lack of ARV access, (as well as for lack of prevention programs) whereas as other less marginalized populations of PLWA have been receiving ARV’s for years.  We would like to see all truly marginalized  populations are represented on CCM’s by Civil Society key actors who are truly committed to fighting for social justice for all communities.   A great deal was said in the Bogotá meeting about inclusion of “vulnerable populations” in the CCM composition, but this seemed mostly focused on sex workers, intravenous drug users, and MSM and transgendered populations. These populations do need to be included in CCM’s as was discussed by you and by numerous other participants in the regional forum.

However,  we are well aware from our own experience in Agua Buena that there is practically no representation of  other populations mentioned above  who are at present perhaps to most likely to be among those who are dying without voice or vote in GFATM countries.  We have wondered about “legitimate representation” of individuals who are the most vulnerable in many countries, mainly because they are the poorest.  Poverty is a leading cause of death by AIDS in Latin America, just as it is in Africa and Asia.  Yet, there is no pro-active plan that would provide ethnic minorities and poverty stricken populations with meaningful representation on CCM’s. 

If the Global Fund were to study the demographics of those who are dying of AIDS in its Latin American and Caribbean  target countries,  the results would clearly show that ethnic minorities, and people living in extreme poverty are the most likely to die at this juncture of the epidemic. These people often, (but with exceptions as well) live in rural areas away from capital cities, where most treatment is provided.    These populations also must be considered as “vulnerable populations.”   We don’t feel that current CCM’s are doing enough to address this issue.

Instead meaningful attention to these especially marginalized groups  seems to be left to “anticipated good will” toward these particular populations from other more empowered CCM members, and, in our experience, this “good will” sometimes does not occur

Local Funding Agents

Regarding the role of the Local Funding Agent (LFA), there is the problem of inconsistent standards of control and monitoring and evaluation by these Agencies.  Although these Agencies receive over 25% of the Global Fund central operational budget, most of them seem far better trained to monitor the financial aspects of the project, than to actually monitor real impact of projects in the field, as was pointed out during the meeting in Bogota.   In our experience this problem is also related to ARV access issues affecting marginalized PLWA who continue to be conspicuously absent in disease related interventions promoted and implemented by CCM’s and PR’s.  If the LFA is fully or partially responsible for determining the outcome the performance based philosophy, then this must occur not in a vacuum, but from a holistic point of view. 

For example, if hypothetical  Principal Recipient “X” has successfully reached their indicator and  placed 1,000 people on treatment in country “y,” during two years, then they may have successfully reached their “indicator.”  On the other hand if, hypothetically,  during this same period, 100 people died because in this same project because of interruptions to their treatment, another 50 died because they could not afford co-payment fees, 50 more died because Physicians refused to start them on treatment because they did not have results of “required” CD4 or Viral Load test results, 50 more died because there was only one first line cocktail and they began treatment already apparently resistant to one or more of these 3 drugs, 100 died because they were “undocumented immigrants” and did not meet national or project enrollment  eligibility criteria for therapy, 50 died for lack of access to medicines for Opportunistic Infections,  and another  100 died because they did not have the money to travel from geographically remote areas to the designated ART clinics, then can we  truly say that “best practice” has occurred and that everything possible has been done to meet the needs of the target populations. Obviously not.   But with respect to investigations by the LFA, the 500 people who died during the period of evaluation of the project were theoretically “invisible,” and the project was “successful.”

In Agua Buena, we are against “punishing” a project which has “failed” to meet an indicator related to  life or death issues.    Those who suffer from these possible punishments are not generally the people working for the Principal Recipient, or those who sit on the CCM, but, on the contrary, the nameless, and  generally impoverished individuals, as described above throughout the letter, who would then be even worse off if project funding is withheld.  The GFATM and its LFA’s  need to focus on truly “holistic” indicators when it comes to performance evaluations in life or death situations, and at the same time pro-actively seek a form of collaborating with PRs and all other key stakeholders to be sure that gaps as described in the hypothetical example are remediated as rapidly as possible.  As such, the “country driven” philosophy must evolve to take into account the constantly occurring gaps which I am trying to describe in this letter. 

Portfolio Managers

Based on our experience in Agua Buena, we have always felt that more Global Fund portfolio managers are necessary, in order to adequately deal with a myriad of complex implementation issues, an issue that was discussed in several forums in Bogotá.    Also we have supported the concept of having trained portfolio managers actually stay in the country for three to six months at a time, or at critical junctures of a project,  so that they can adequately understand all of the complexities of project implementation and intervene when necessary.  We do not want to create “another UN Agency” but many   other key actors in the region have raised this issue, given the complexity and gravity of problems that have occurred over the past five years in project implementation in many countries in Latin America and the Caribbean.

We do not think that Portfolio Managers should be providing technical support as such, however they need to be available to  help CCM’s and PRs make timely decisions as to when technical support is appropriate, and how to best obtain it.    We are also concerned that expectation for  technical support is often focused on over-worked UN Agency staff, who have a dozen “priorities” to attend to at the same time. I am not “defending” UN Agencies, as such, I am simply pointing out a reality.    For us, one issue that was omitted, or perhaps not adequately emphasized in the numerous discussions about technical support at the Bogota forum, relates to making technical support sustainable at the national level.    UN Staff, as well as other “consultants” come and go, but the real issue is having committed health care professionals at the national level be available permanently to provide this kind of support and assistance, and the Global Fund also needs to think creatively and pro-actively regarding this issue. 

User Fees”  in GFATM Target Countries

An issue that the GFATM needs to consider addressing is ‘user fees’ for ARV’s purchased with GFATM funds. In two of our target countries, Honduras and Jamaica , all people receiving ARV’s at public clinics must be evaluated by a Social Worker and will be charged according to “ability to pay.”  But information we have gathered over the past three  years indicates that many poor people are charged what may seem to be relatively small co-payments for example, from $3 to $17 per month, but while these people may have funds at a given moment, we very often see that at a later point in time they are unemployed, and no longer have resources,  and have to choose between food for families and ARV’s. We know that the issue of user fees affects adherence among PLWA, many of whom are always living on the brink of poverty. 

In some cases, Social Workers simply are not able to accurately evaluate the ability of poor people, beset by overwhelming obstacles to make even a small payment, and to provide follow-up when financial realities change.     In summary,  in poor countries the infrastructure provided to evaluate the ability of PLWA to handle these fees is insufficient and PLWA fall through the cracks, resulting in them either missing a month or more of treatment, or in some cases, discontinue treatment altogether.  

We know that people die because of these user fees in both Honduras and Jamaica . 

At one point, we were told that the Global Fund does not permit, or at least, strongly discourages user-fees in relation to products it is providing to the country with its own funds.     Could you please clarify this policy for us, as our own attempts, along with those of other activists, to end the user fee system in these two countries has not been successful?

The New Rolling Continuation Channel

During the Bogota meeting there was discussion about the Rolling Continuation Channel (RCC).  As it was explained, the  R CC is a procedure designed enable high performing projects to receive six more years of GFATM support, without having to go the procedure of applying for an entirely new grant. Rather, they are designated by the Fund as being eligible for RCC, and then can “choose” to submit an apparently simpler application to the Technical Review Panel for approval for continuation of their current project.   

However, what became quite clear during the meeting, and was pointed out by Dr. Rolando Pinel of the Honduran CCM, is that there is no guarantee that even these projects will be accepted to the Technical Review Panel (TRP).  As such, this seems “reasonable.”  What seems unreasonable is that there is no give and take between the TRP and the CCM regarding potential pitfalls in the R CC submission which would cause it to be rejected.    As it with regular grant applications, as it currently stands, the situation is “all or nothing.”    Yet, Honduras , received the offer to apply for R CC because of their excellent performance in their Round 1 grant, but if the proposal they submit is incongruent with TRP expectations, they suddenly find themselves without any project.   As I pointed out during this discussion in Bogotá, it seems imperative that there be some feedback between the TRP with  those countries who choose to use the R CC mechanism, so that a project that is been “rewarded” for its superior functioning is not suddenly faced with the complete termination of its project.   

It was mentioned that countries eligible for R CC can also simultaneously apply for a regular Round 8 grant, but this seems to be a cumbersome and almost contradictory option. If an extension is being offered by means of R CC, then every effort should be made to see that countries eligible for the R CC are aware of the expectations of the TRP, in relation to the parameters they are required to deal with in their R CC application.    Every effort should be made to assure that no R CC project is rejected; even if that means that some guidelines utilized by the TRP, and, finally, by the Board, need to be modified.   

I sincerely appreciate your time and attention, both in Bogotá, and, if possible,   in relation to some of the issues I am raising here.


Richard Stern
Agua Buena Human Rights Association
San Jose, Costa Rica
Tel-Fax 506-2280-3548, 506-390-5213



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