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Section: Regional
March 24, 2008

A Call for transparency in the preparation of Round 8 Global Fund Grant Proposals in Latin America

Marzo 24, 2008

Richard Stern
Agua Buena Human Rights Asociation
San Jose, Costa Rica
Tel/Fax +506-22803548

In Latin America, the earliest Global Fund Proposals were often prepared by paid consultants who had the ability and expertise to   work effectively within the context of the extensive and complex application procedures. Often, government officials and others on the CCM sought out these individuals and turned over much of the grant preparation process to them.  In some cases, grants which were approved in these proposals were actually beyond the local “implementation capacity” of national governments and other implementing bodies. In other cases the grants were very appropriate to the needs of the country and to its ability to effectively carry out projects.

There was relatively little Civil Society participation in the earliest grant applications.  As time has passed Civil Society organizations, including PLWA organizations have clearly become much more involved in the preparation of grants.  But it remains a difficult task to include input from all affected sectors as to their individual needs and these “sectors” vary considerably within countries in their ability to access the planning process for proposals.

I. Gaps in access which must be addressed in Round 8 Proposals

Current Global Fund grants have dramatically increased the number of PLWA who receive treatment in many Latin American countries, as well as countries around the world.   Yet, in our own investigations in our target countries, we frequently find important gaps in services, even when resources from the Global Fund are combined with other resources.

Such gaps include but are not limited to:

1)       Lack of health care infrastructure and availability of commodities in geographically isolated areas.  In rural areas of countries such as Honduras, Nicaragua, Bolivia, and Guatemala, PLWA must frequently travel long distances to receive HIV tests, anti-retroviral medications, CD4 and Viral Load testing, and many other components related to comprehensive access to care and treatment.

2)       Lack of availability of medications for Opportunistic Infections in urban as well as rural clinics.  Often, neither the national AIDS program, nor the Global Fund project are providing these medications in a timely fashion, resulting in many needless deaths.

3)       Lack of availability of reactives and/or appropriate equipment for timely availability of CD4 and Viral Load testing in urban as well as rural areas. Lack of trained laboratory staff to carry out testing.

4)       An almost total lack of availability of resistance testing in the region’s poorest countries, so called lower-middle income countries, such as but not limited to Honduras, Nicaragua, Guatemala, Jamaica, and the Domincan Republic.

5)       Lack of an adequate budget built incrementally into projects to provide   2nd line medications which are more expensive, but more and more necessary as more PLWA have been on treatment longer and require these medications. 

6)       Lack of availability of pre-natal testing for pregnant mothers and availability of PMCT interventions in rural and urban areas.

7)       Lack of appropriate “outreach” to inform poor and geographically marginalized populations of the availability of treatment, and lack of appropriate support in order to assist these populations in accessing treatment.

8)       Lack of appropriate early interventions to detect HIV/TB co-infection, and appropriate treatment to deal with co-infection.

9)       Lack of ‘discretionary’ funds programmed into a project which are necessary when new discoveries are made which create new ‘standards of care.’ This is occurring throughout the region now that regimens which include d4T are no longer recommended because of toxicity, meaning that a more expensive regime which includes Truvada (or ATRIPLA) should replace d4t based regimens as first line interventions.

10)   Lack of incentives and support for  trained physicians and nurses to relocate to rural areas

11)   Marginalization of ethnic minorities and ‘vulnerable’ populations affecting their ability to receive comprehensive care.  This may include indigenous populations in countries such as Honduras and Guatemala or immigrant populations, such as Haitians living in the Dominican Republic, and migratory workers throughout Central America.

12)   Lack of adequate, planning, coordination, and cooperation between National AIDS programs and Global Fund projects in many proposals, which result in the gaps which are mentioned in this list. 

13)   Lack of mechanisms which improve adherence in all affected populations, in terms of an analysis of factors contributing to poor adherence and/or abandonment of treatment.  Lack of effective treatment literacy programs which could reduce abandonment of treatment.

14)   Lack recognition and appropriate interventions focused on the major group in which AIDS mortality occurs: PLWA  who finally arrive at appropriate clinics in such a late stage of disease progression that it is too late for them to benefit from ARV therapy. Reasons for this delay in accessing services must be analyzed and addressed in project proposals.

15)   Lack of accurate statistics regarding AIDS incidence and mortality throughout most of the region.

It seems particularly tragic that even with funds provided by the Global Fund, that so many PLWA still ‘fall between the cracks’ and continue to die because of the above gaps in comprehensive care, as well as other problems that may have been omitted from this list.

II. The Global Fund’s Point of View

In the most recent edition of the Global Fund Observer, Dr Michel Kazatchkine, Executive Director of the Fund pointed out that: "Antiretroviral therapy reaches only 30 percent of those in need, and multidrug-resistant TB looms as a serious threat in many countries. A lot of people at risk of malaria still do not sleep under a bed net or do not have access to treatment.  Now is the time for nations to aim high by mobilizing government, NGOs and international partners and submitting even more ambitious proposals for Global Fund financing."  In Latin America and the Caribbean, many countries, especially lower middle income countries, only approach 50-60 percent access, but, unfortunately, there has not been adequate attention paid to this reality, for a variety of factors. Dr. Kazatchkine is clearly inviting nations who still do not have universal access to use Round 8 to submit proposals aimed at closing the ARV access gap. But the Global Fund will not mandate such proposals, due to its ‘country driven’ philosophy.  There is a lot of ‘lip service’ being paid to the cry for universal access by 2010, but nearly halfway through 2008, this goal seems to be just  a pipedream

In the meantime planning for Round 8 proposals is underway in many Latin American countries. I would like to suggest that it is urgent that the issues listed above must be addressed in these project proposals.   Over the years Networks of PLWA and urban NGO’s have indeed become increasingly involved in the development of project proposals. The Global Fund, as well as other donor sources have played a critical role in supporting  the capacity of these PLWA leaders to participate in the planning and writing of GFATM proposals.

III Addressing Potential Problems within PLWA groups and other Sub-receptors

Yet, to be sincere, even these groups do not always take into account the health related needs of more marginalized populations with whom their own contact may be limited.   I would hope that these PLWA leaders, who have now become part of the ‘mainstream’  would always try to prioritize the health related needs of all PLWA in any given country, yet, time and again, history has shown that this may not be the case, for any number of reasons

One way to increase the probability that gaps in comprehensive care are overcome is to increase the transparency in the planning process to reach out to populations of PLWA who are known to fall between the cracks because of poverty, ethnic origin, geographic isolation, discrimination, and a wide range of other factors.   In order to do this, there must be transparency in the process of developing the proposals for Round 8 and an effort must be made to disseminate information and seek feedback about evolving proposals at a National and Regional level.

Bolivian AIDS activists have created an e-forum which is widely distributed, and provides detailed information, practically on a case by case basis, of those who are excluded from comprehensive care and treatment. This e-forum also encourages transparency in terms of how all affected NGO’s should communicate with their various constituencies. In my opinion, an effort needs to be made to develop a similar e-forum in all of the other countries in the region where significant gaps in ARV access are occurring.

Unfortunately, even as the Global Fund presents tremendous opportunities for the expansion of care and treatment, and for progress toward universal access, it also provides the incentive of large budgets for Civil Society NGO’s whose priorities may or may not always be congruent with the best interests of those who are still without treatment access. .  In a Health Gap Posting in January of 2007 Eugene Schiff stated that: “Sometimes there is a thin and gray line between "real" activists and also genuine former activists (particularly before there was any ARV access for almost anyone in their country or community and there was a real life or death struggle to be fought) and others who are hardly activists or committed at all to urgently expanding treatment access or social justice.   Many switch back and forth as opportunities and opportunism or difficult challenges arise.  It is rarely black and white…” 

Not every NGO needs to work in the area of comprehensive care. Many may focus on prevention, or outreach to vulnerable populations such as MSM and sex workers, or  capacity building of PLWA, and this is entirely valid.

In fact, there has clearly been strong pressure from communities in the past several years  to be sure that adequate funds in GFATM projects are made available to PLWA run NGO’s and networks.  Also there are now many new resources and initiatives available for supporting PLWA groups in submitting proposals which will enable them to  become sub-receptors in GFATM grants. This is largely a ‘positive’ process, but it would be  ironic and paradoxical, if the strengthening of these organizations and networks does not also contribute to significantly lowering the mortality in the PLWA affected populations. 

In my opinion, unless the overarching concern of access to life saving medications, and all that this implies, is adequately addressed in Round 8 proposals, than there is a ‘moral vacuum’ that is not being filled.  The underlying and fundamental premise of ‘access for all’ must always be prioritized in the development of proposals. If and when significant amounts of funds are allocated to Civil Society organizations, and the amount of these funds somehow “limit” the amount of funding available to assure universal access, then something has gone terribly wrong.

IV. Opportunities for Transparency in Round 8 Proposals

During the next few months there is an opportunity for transparency in project planning as the number of civil society representatives on CCM project planning committees increase. This is a call for these representatives to reach out to all affected sectors and seek input as to the needs of those populations who are in situations of high risk for death  due to AIDS. It is also a call for these representatives to carefully analyze gaps in existing care, as listed above (and other gaps that have undoubtedly been omitted)  and to seek input from physicians, and health care system experts at a national and regional level, so that gaps in access will be reduced during the period from 2009-2013, as a result of Round 8 proposals.  

It is a call for ‘closed cadres’ of individuals and groups, from any and all sectors,  to refocus their priorities, and increase their degree of openness to input from their real constituencies.    It also is a call to confront those NGO’s whose ties to high level government officials are likely to  put them in a position of morally compromised leadership when it comes to proposal planning. In past rounds, it is clear that some NGO’s in the Latin American region were forced into this position by government manipulation. At this point, after five years, no one would doubt that one of the negative bi-products of the Global Fund has been divisions among leading PLWA groups that were formerly united.  The current make up of CCM’s reflects a five year history in which equal representation of all sectors has not been guaranteed, even though the GFATM’s recent policies related to CCM composition attempt to impact on this problem. 

Even for Round 8, it is probable that the final drafts of most proposals will be prepared by an ‘elite’ group of experts (often still more allied with government than with Civil Society) after which others who may have given input will be asked to sign the proposal. I feel that it is imperative  that a simplified and easily understandable version of the final draft of all proposal components must be presented to as wide as possible a range  of interested organizations, and affected individuals before anyone is asked to sign on to anything.  There is still time to plan for this need, although historically most proposals are finally completed only at the last minute, and, therefore, there is no opportunity for a wider distribution to affected populations in order in order to evaluate how those who have drafted the proposal have interpreted feedback received from various sectors, and translated this feedback into a final proposal. 

As mentioned above,   information gathering must be built into the application process and it seems imperative that each CCM should hold an ‘expert consultation’ on treatment access issues which would involve National AIDS program staff, current Principal Recipients, the entire CCM,  local physicians and experts on treatment access from the international agencies of cooperation such as WHO, UNAIDS, PAHO and others.   The consultation should consider issues related to AIDS mortality in the national context, and the group should make recommendations focused on access related issues which need to be prioritized in the Round 8 GFATM grant application.

V ‘Country Driven’ approach  implies responsible national action

The Global Fund process is ‘country driven’ and the fund limits itself to ‘guidelines’ in terms of how proposals must be written and to how inclusiveness can be enhanced in the preparation of proposals.  Of course, signatures from CCM members are required that attest to this ‘inclusiveness,’ but the Global Fund, as it presently exists, cannot possibly evaluate accurately what is really occurring “on the ground” in terms of how any given proposal was developed. And, in fact, if the final signed proposal does not include treatment access components leading to comprehensive care and universal access, the Fund will not intervene and the Technical Review Panel in Geneva will evaluate the proposal exactly as it is.  For Round 8 the Fund is asking for two or more principal recipients per country, one from Civil Society and one from Government.  If comprehensive care and access is to be a primary focus in proposals, its seems important that proposed Principal Recipients be organizations with a proven commitment to access related themes and that they also have the technical skills necessary for rapid implementation of projects focused on ARV access.

Guides in six languages focusing on technical aspects of preparation of proposals  for round 8 are provided by Aidspan at:   In reality, few PLWA with little or no internet access, and who frequently  live in impoverished conditions in marginalized communities,  are likely to have direct access to the Aidspan guides, or other documents provided by the GFATM. So it is imperative that Civil Society representatives fulfill their mandates and seek to address the urgent needs of these communities in Round 8 proposals.

It is up to all those stakeholders who have a moral commitment to stopping the unnecessary deaths that still occur in Latin America (and world wide) to work to increase transparency in the proposal process, to put their differences aside, and, as an overarching issue,   to prioritize the saving of human lives in each country where this necessity exists.


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