Global Fund Observer Issue 133

[Guest guest]

GLOBAL FUND OBSERVER (GFO), an independent

newsletter about the Global Fund provided by Aidspan to over 8,000 subscribers in

170 countries.

Issue

133: 15 November 2010. (For formatted web, Word and PDF versions of this and

other issues, see www.aidspan.org/gfo.)

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CONTENTS

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1. NEWS: TRP Recommends for Approval 89 Round 10 Proposals; Total

2-Year Cost Is $1.76B

If the Global Fund Board approves all 89 proposals recommended

by the Technical Review Panel (TRP), the $1.76 billion cost would make Round 10

the third largest round ever of Global Fund grants.

2. COMMENTARY: The Global Fund Should Move Now to Expand the

Non-CCM Window

It is evident that in many countries

the needs of key populations are not being addressed by the national response,

at least with respect to HIV. It's time for the Global Fund to make some

changes to the eligibility criteria for Non-CCM proposals so that civil society

organisations can help fill this gap.

3. NEWS: Global Fund Releases New Operational Policy Manual

The new Operational Policy Manual was developed to

assist Global Fund Secretariat staff to provide guidance on Global Fund policies

and processes relating to grant management. The manual will also be of interest

to grant implementers.

4. ANALYSIS AND COMMENTARY: The Counterfeit Drugs Issue Deserves

More Attention

The use of counterfeit medicines is widespread,

affecting numerous countries on at least three continents, and negatively

impacting the implementation of Global Fund grants.

5. NEWS: Request for Phase 2 Funding for a Zanzibar HIV Grant Is

Turned Down

In October, when the Global Fund Board rejected a

request for funding for Phase 2 of a Round 6 HIV grant in Zanzibar

(Tanzania),

it was only the second time in three years that the Fund declined to approve a

Phase 2 request. Some Board members opposed the decision.

6. COMMENTARY: Casting a Vote Against (Some) Electronic Voting

The Global Fund Board's system of electronic voting

for taking decisions between Board meetings does not work very well for controversial

decisions, such as declining a request for Phase 2 funding.

7. ANNOUNCEMENT: UNDP Is Recruiting an International Consultant

Some of the work of this consultant will directly

involve the Global Fund.

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1. NEWS: TRP Recommends for Approval 89 Round

10 Proposals; Total 2-Year Cost Is $1.76B

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The

Global Fund's Technical Review Panel (TRP) has recommended that the Global Fund

Board approve 89 Round 10 grants that, over their first two years, will cost

$1.76 billion. This makes Round 10 the third largest round ever of Global Fund

grants (after Rounds 8 and 9).

The

TRP reviewed a combined two-year funding request of $4.38 billion, representing

150 disease components and 28 health systems strengthening (HSS) components.

GFO

has no information on which specific components the TRP has recommended for

Board approval. But Board members have been informed by the Secretariat of some

overall data. Highlights from what Board members were told, and from GFO's

analysis of that information and of comparisons with Round 9, are presented

below. (For the purposes of this article, we refer to all disease and HSS

components as " proposals. " )

Eighty-nine

Round 10 proposals have been recommended for approval, with a total

two-year cost of $1.76 billion (at current exchange rates), down from

$2.21 billion in Round 9 and $3.1 billion in Round 8.

The average Round 10 proposal recommended for

approval has a two-year cost of $20 million, down from $23 million in

Round 9.

The number of proposals recommended for approved

in Round 10 (89) is down slightly from the number recommended in Round 9

(96).

Fifty percent of proposals considered by the TRP

in Round 10 have been recommended for approval, almost identical to the

rate in Round 9 (51%).

Proposals for malaria were the most successful

in Round 10, with 79% of submitted proposals recommended for approval,

compared with 54% for TB, 43% for HSS, and only 41% for HIV. The success

rate for malaria is up significantly from Round 9. See the table below for

more details.

Table: No. of

proposals reviewed and recommended, for Rounds 10 and 9

Round 10

Round 9

Proposals

reviewed by TRP

Of which, recommended

for approval

% recom-mended

Proposals

reviewed by TRP

Of which,

recommended for approval

% recom-mended

HIV

78

32

41%

73

30

41%

Malaria

24

19

79%

31

17

55%

TB

48

26

54%

53

32

60%

HSS

28

12

43%

33

17

49%

Total

178

89

50%

190

96

51%

The

TRP completed its review of proposals on 30 October 2010. Individual applicants

should be informed shortly, if they have not already been, of what the TRP has recommended

regarding their specific proposals. Then, on 13-15 December, the Board will

make a final decision regarding each proposal.

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2. COMMENTARY: The Global Fund Should Move

Now to Expand the Non-CCM Window

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by

Garmaise

When

is the Global Fund finally going to make it easier for Non-CCMs to apply to the

Fund to address the needs of vulnerable populations that have been left out of

the national response?

The

Global Fund has always discouraged applications from Non-CCMs. (Non-CCMs are

national organisations other than the CCM - usually, but not necessarily, civil

society organisations.) Under current criteria, Non-CCMs can apply only if they

are from a country that is without a legitimate government, that is in

conflict, that is facing a natural disaster, or that is in a complex emergency

situation - or if they are from a country that suppresses, or has not

established, partnerships with civil society. The last includes a country in

which the CCM has unreasonably failed or refused to consider a submission from

a civil society organisation, through the CCM's established submissions

process, for inclusion in the CCM's national proposal.

The

criteria state that a Non-CCM proposal must demonstrate clearly why it could

not be considered under the CCM process.

The

table below shows what has happened to Non-CCM proposals in recent rounds.

Table: Disposition

of Non-CCM proposals in Rounds 5-9

Round

No. of proposals submitted

No. of proposals deemed eligible and sent to the TRP for

review

No. of proposals recommended by the TRP and approved by the

Board

5

64

4

2

6

36

4

1

7

16

3

2

8

20

0

0

9

14

0

0

Totals

150

11

5

Thus,

of the 150 Non-CCM proposals submitted in Rounds 5-9, more than 90% were

screened out (i.e., deemed ineligible according to the eligibility criteria).

The most common explanation provided for screening out these proposals was that

the applicant had failed to explain why it had applied outside its national

CCM.

Of

the 11 Non-CCM proposals screened in for Rounds 5-9, 10 were from countries

without legitimate governments or in conflict. The only other Non-CCM proposal

screened in was submitted by the Russian Harm Reduction Network. That proposal,

which targeted injection drug users, was approved for funding. One other

Non-CCM proposal targeting injection drug users was approved in Round 3. The

principal recipient (PR) was the Raks Thai Foundation, from Thailand. Thus, in the last seven

rounds of funding, only two Non-CCM proposals exclusively targeting a key

population have been approved.

Programmes

providing services to key populations often don't get off the ground because:

(a) many governments don't like dealing with key populations; ( in most

countries, nothing gets through the CCM that the government is opposed to; and

© very few Non-CCM proposals ever get approved.

For

each Round of funding, the Global Fund Secretariat establishes a Screening Review

Panel (SRP) made up of senior officials in the Secretariat. Since at least

Round 7, the SRP has issued reports on the screening process. In each of its

reports on Rounds 7, 8 and 9, the SRP has commented on the eligibility criteria

for Non-CCM proposals. In its Round 7 report, the SRP said:

" There may be a need to evaluate the role of

non-CCMs and how revisions to our current policy may enhance scale-up beyond

the CCM model. If the Global Fund wants to expand opportunities for

multi-partner scale-up, then the current non-CCM window of opportunity are

narrow, [thus] limiting the range of funding possibilities. The Secretariat

should review the role of Non-CCMs for Round 8 and seek guidance from the Board

on additional ways to expand funding opportunities that conform to national

plans yet open the avenue towards funding more non-national plan

proposals. "

In

its Round 8 report, the SRP said:

" The non-CCM window remains an opportunity for

groups marginalized as a result of stigma and discrimination in government

policies. The Secretariat could better define 'key and vulnerable populations'

and determine eligibility of non-CCM proposals on the basis of the target

population. "

In

its Round 9 report, the SRP said:

" The non-CCM application option remains an important

opportunity for groups marginalized as a result of severe stigma and

discrimination in government policies, particularly regarding proposals

addressing HIV/AIDS.

" Based on success rates since Round 6, it is

clear that more guidance is needed from the GF on when a non-CCM application is

appropriate, and on what documentation is necessary to support a request for

funding outside of the CCM model. "

So,

here we have the SRP, which is part of the Secretariat, recommending that the

Secretariat review the eligibility criteria for Non-CCM proposals with a view

to expanding the use of the Non-CCM window. And, yet, no action appears to have

been taken by the Secretariat (or the Board) on this recommendation.

In

a GFO commentary in 2006,

Promboon Panitchpakdi, Executive Director of the Raks Thai Foundation, said

" the Global Fund needs to do more to strengthen the involvement of civil

society, including encouraging the development of NGO components that are not

hidden within government-inspired CCM proposals (and/or making it easier for

non-CCM proposals to be funded). "

In

a GFO commentary in 2008, this

author said:

" The Global Fund has done such a good job of

discouraging applications from Non-CCMs that (a) the number of such

applications has declined in every successive round; and ( civil society

advocates have all but abandoned efforts to persuade the Fund to accept more

Non-CCM applications. But now we have a report from the Round 7 Screening

Review Panel saying that maybe the Fund should re-think its policy ... yet this

aspect of the report seems to have garnered little attention. There ought to be

further discussion of this at the level of the Global Fund Board and within

civil society. "

in

its 2009 AIDS Epidemic Update, UNAIDS said that even though key populations -

such as injecting drug users, men who have sex with men, sex workers, prisoners

and mobile workers - are at higher risk of HIV infection, resources for focused

prevention programmes for these groups is typically quite low, even in

concentrated epidemics.

It

is evident that in many countries, the needs of key populations are not being

addressed by the national response, at least with respect to HIV. It's time for

the Global Fund to make some changes to the eligibility criteria for Non-CCM proposals

so that civil society organisations can help fill this gap.

Garmaise (david.garmaise@...)

is a Senior Analyst with Aidspan. Reports of the SRP are available at www.theglobalfund.org/en/ccm/documents.

The two GFO commentaries mentioned in this article are " The

Imbalance Between Government and Civil Society in Global Fund Processes: A View

from Thailand, " GFO 65; and " Report

on Round 7 Screening Raises Some Important Issues, " GFO 92, both

available at www.aidspan.org/gfo. The

UNAIDS 2009 AIDS Epidemic Update is at www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2009.

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3. NEWS: Global Fund Releases New Operational

Policy Manual

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The

Global Fund has issued a new 229-page Operational Policy Manual, developed to

assist Global Fund Secretariat staff to provide guidance on Global Fund

policies and processes relating to grant management. The manual will also be of

interest to grant implementers - and, to a lesser extent, grant applicants.

(The

Global Fund used to have an earlier version of this manual, but it was not

widely available and was not kept up to date.)

Although

the manual is perceived by the Global Fund as mainly an internal document, it

is posted on the Fund's website where anyone can download it. The manual

complements the Operational Guide, which was designed for an external audience

and which was released a few months ago (see " Global

Fund Releases Detailed Operational Guide " in GFO 129.)

The

manual contains operational policy notes (OPNs) and information notes (INs).

OPNs explain how steps in the grant cycle must be managed. Each OPN integrates

policies approved by the Board and procedures established by the Secretariat.

INs provide more general information on concepts (such as alignment), funding

streams (such as national strategy applications) and entities (such as

principal recipients).

On

most topics of interest to grant implementers, the manual provides more

in-depth information than the Operational Guide. For example, on the subject of

the Global Fund's Additional Safeguard Policy (ASP), the Operational Guide

contains a very short introduction to the topic, whereas the Operational Policy

Manual contains a three-and-a-half page OPN that, among other things, outlines

the criteria for invoking the ASP, describes the seven minimum safeguards under

the policy, and explains how the annual reviews of grants managed under the ASP

are conducted.

Other

OPNs in the manual cover topics such as amending grant agreements, grant

extensions, enhanced financial reporting, and the pre-allocation of grant

funds. The Global Fund Secretariat will be adding to the manual over time; some

of the items listed in the table of contents are labelled

" forthcoming. "

There

are some apparent gaps in the topics covered - for example, programme income

(i.e., funds generated through social marketing and user fees), and grant

suspensions - but it is not clear whether the Global Fund has formally adopted

policies and procedures for every topic.

One

implementer told GFO that the

manual is a " huge step forward, " but that there are areas for

improvement. In the past, principal recipients (PRs) often felt constrained in

their dealings with fund portfolio managers (FPMs) because they didn't know

what " rules " the FPMs were following. Now, at least, PRs have access

to much of that information.

" The Global Fund Operational Policy Manual " is

available in English only at www.theglobalfund.org/en/policies.

The " Operational Guide " is available on the same page.

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4. ANALYSIS AND COMMENTARY: The Counterfeit

Drugs Issue Deserves More Attention

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by

Garmaise

As

reported recently in GFO, the Global Fund's Office of the Inspector General

(OIG) is investigating allegations that malaria drugs funded through Global

Fund-supported programmes are being stolen and then sold in the private sector

for profit. (See " Report

Renews Concerns About Stolen Malaria Medicines " in GFO 131.) There is no indication yet that this

a widespread problem. However, the use of counterfeit medicines, which is

linked to the sale of stolen medicines, is definitely a widespread problem,

affecting numerous countries on at least three continents (Asia, Africa and Europe).

Just

how big a problem is it? What are the repercussions? How does it affect the

Global Fund? Can or should the Global Fund do anything about it?

" Nobody

knows the full scope of the crime, although the World Health Organization (WHO)

estimates that counterfeit drugs are associated with up to 20 percent of the

one million malaria deaths worldwide each year, " wrote Marshall in

the magazine sonian in October 2009. " Reliable statistics ... are

hard to come by, partly because the damage seldom arouses suspicion and because

victims tend to be poor people who receive inadequate medical treatment to

begin with. "

" Rich countries have long employed expensive methods, like tracking

systems or sophisticated equipment, to verify whether drugs are

authentic, " but countries in Africa can't

afford these methods, wrote Cheng of the Associated Press in 2010.

Studies by the WHO and other agencies have shown that a significant percentage

of medicines in Africa are counterfeit or substandard (30% or higher in some

parts of Africa).

According

to Cheng, " Fake drugs can infiltrate shipments even when it's the United

Nations or the Global Fund to Fight AIDS, Tuberculosis and Malaria that is the

sender. Last year, malaria medicines dispatched to Ghana by the Global Fund

mysteriously went missing. Once the drugs arrived in the country, they were

replaced by counterfeits, leading Ghanaian authorities to investigate

allegations a cartel was replacing real drugs with fake ones. "

In

a report on an audit conducted in 2009 on programmes supported by the Global

Fund in Cambodia, the OIG

said that " Cambodia

has a high prevalence of counterfeit and substandard drugs, " included

artemisinin-based combination therapies (ACT) and drugs for opportunistic

infections (OIs). The OIG cited a University of the South Pacific report from

June 2009 showing that 27% of artesunate (a drug that is part of the

artemisinin group) being distributed in Cambodia was counterfeit. The OIG

said that a similarly high percentage was reported for some OI drugs. " The

laws that would help curb the proliferation of counterfeit and substandard

drugs were in place but law enforcement was weak, " the OIG said.

" Urgent action is needed to address this problem. "

According

to Marshall, between 1999 and 2003, medical

researchers conducted two surveys in which they randomly purchased artesunate

from pharmacies in Cambodia,

Myanmar, Laos, Thailand

and Vietnam.

The volume of fake pills was 38% percent in the earlier survey and 53% in the

later survey.

Counterfeit

drugs - which are often mostly flour or sawdust or baby powder - end up killing

people. Malaria is a deadly infectious disease, but it usually is curable if

treated early with appropriate drugs. Patients who think they are taking the

right medicines, but who are actually taking counterfeit medicines, will likely

die from the disease.

And

that's not the only problem. Fake medicines speed up drug resistance. " If

a drug contains some but not enough of the active ingredient, it won't kill the

disease's virus or bacteria, but gives it a chance to mutate into a deadlier

form instead, " Cheng said.

The

WHO says that clinical trials conducted in 2007-2008 confirmed the emergence of

artemisinin resistance along the Thai-Cambodian border. " This is extremely

serious because resistance to a number of formerly-effective malaria drugs

originated from the Thai-Cambodian border and then spread west to South Asia,

then Africa - where most malaria deaths occur, " the WHO says. " If

this were to occur with artemisinin, millions of lives could be at risk. It

would also be a huge setback to intense international efforts over recent years

to combat the threat of malaria globally. "

The

problem affects Global Fund grants because they are funding treatment to save

lives. The presence of counterfeit drugs, the existence of drug resistance, and

the threat of even higher drug resistance negatively impact the ability of

grant recipients to meet their targets.

Should

the Global Fund do anything about it? In accordance with the core Global Fund

principle of country ownership, shouldn't the onus be on countries to address

this problem in their proposals? Perhaps; and, indeed, some countries are doing

so - for example, a Round 6 malaria proposal from Laos was devoted almost

entirely to reducing the use of counterfeit medicines. However, the Global Fund

has actively supported the development of programmes to address other problems

- for example, gender inequalities, human rights abuses, and mother-to-child

transmission of HIV; and it has promoted interventions to strengthen health

systems and community systems. Why not also promote interventions to address

the counterfeiting problem?

At

a minimum, the Global Fund could produce an information note outlining the

problem and describing different interventions currently being used by

international agencies and individual countries to combat the problem. It may

also be possible to produce some " best practice " case studies to help

countries learn from each other's experiences.

Garmaise (david.garmaise@...)

is a senior analyst with Aidspan. Some of the information for this article as

taken from " The Fatal Consequences of Counterfeit Drugs, " by

Marshall, sonian, October 2009, at www.smithsonianmag.com/people-places/Prescription-for-Murder;

" Africans Text Message to Check if Drugs Are Real, " Cheng,

Associated Press, 2010, at www.physorg.com/news201535471;

and " Battling Drug Resistance Along the Thai-Cambodian Border, " WHO,

online at www.who.int/malaria/diagnosis_treatment/arcp/faq/en. The article by Cheng describes how text

messages are being used in Kenya

to help people check if their medicines are genuine.

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5. NEWS: Request for Phase 2 Funding for a Zanzibar HIV Grant Is

Turned Down

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In

October 2010, the Global Fund Board rejected a request for funding for Phase 2

of a Round 6 HIV grant in Zanzibar (Tanzania),

based on a recommendation from the Global Fund Secretariat. (This is referred

to as a " No-Go " recommendation.) Some Board members opposed the

decision. This is only the second time in more than three years that the Global

Fund has declined to approve a Phase 2 request. The first time was just a

couple of months ago (see " Board

Rejects Request for Phase 2 Funding from Sri Lanka " in GFO 130).

In

line with Board policy, in May 2010 the Secretariat notified the Zanzibar

Sub-CCM that it was planning to make a No-Go recommendation to the Board, and

the Sub-CCM had an opportunity to respond. After considering the response, the

Secretariat re-affirmed its No-Go recommendation and the Board accepted the

recommendation in an electronic vote.

The

Secretariat said that the recommendation not to continue the grant was made

strictly in accordance with the principles of performance-based funding.

According to the Secretariat, results were well short of target; the

performance of the principal recipient (PR), the Zanzibar AIDS Commission, was

clearly inadequate (for example, there were significant weakness in human

resource management, sub-recipient management, M & E and reporting); and the

PR consistently failed to address the underlying causes of that poor

performance.

The

Secretariat said that although it regularly reiterated the need for long-term

technical assistance and capacity building to address grant challenges, the

Sub-CCM did not attempt to secure technical support from local or international

partners in a timely manner.

The

Secretariat stated that the discontinuation of this grant will not lead to

interruptions in antiretroviral treatment (ART) or to new ART patients being

turned away, because ART activities will continue to be supported by another

Round 6 HIV grant with the Ministry of Health and Social Welfare.

When

the Board made its decision, there were some dissenting votes, but not enough

to block the No-Go recommendation from going through. (See the commentary

below.)

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6. COMMENTARY: Casting a Vote Against (Some) Electronic

Voting

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by

Garmaise

The

Global Fund Board meets in person usually twice a year. In between meetings,

the Board uses an electronic voting system (i.e., voting by email) for

decisions that can't wait until the next in-person meeting. That's fine for

routine decisions where there is unlikely to be much discussion or opposition,

such as extending the deadline for grant agreement signing for a few grants.

However, it doesn't work very well for decisions that are more controversial or

decisions that can have significant adverse effects on countries.

Twice

in the last few months, the Global Fund Board has approved by electronic voting

recommendations from the Secretariat not

to approve Phase 2 funding - once for a TB grant in Sri Lanka (see " Board

Rejects Request for Phase 2 Funding from Sri Lanka " in GFO 130) and more recently for an HIV

grant in Zanzibar (see previous article). In both instances, the No-Go

recommendations were opposed by some Board delegations, but not in sufficient

numbers to block the recommendations.

When

the Board votes electronically on a recommendation from the Secretariat, an

email is sent out to all Board delegations. Votes on Phase 2 recommendations

are on a " no objection " basis - i.e., only those delegations that

object to the recommendation are required to vote; a delegation that does not

cast a vote is considered to have " voted " in favour of the

Secretariat's recommendation. Delegations opposed to the recommendation are

asked to vote via reply email by a set deadline. These delegations have an

opportunity in their reply email to comment on why they are opposed. The usual

practice is for a delegation to copy other delegations when it votes.

The

main problem lies in the fact that when a delegation is opposed to a No-Go

recommendation from the Secretariat, its vote and the arguments it advances in

support of its vote are all contained in the same email. There is no

opportunity for discussion among Board delegations before the vote. For

example, if Delegation A objects to the recommendation from the Secretariat,

and attaches arguments in support of its position, other delegations may see

these arguments. But some or all of these delegations may have already

determined how they will vote by the time they see what Delegation A said.

If

this were an in-person Board meeting, before a vote is taken, Board members

would get to hear the arguments on both sides. Plus, they would be able to ask

questions of the Secretariat. Board members might be influenced by what they

hear. The electronic voting process does not allow for that same dynamic.

One

solution would be not to allow potentially controversial decisions (such as

No-Go recommendations) to be made by electronic voting. But this may prove

problematic, given the urgency of some of the decisions and the fact that the

Board only meets in person twice a year.

Another

solution would be to require potentially controversial decisions to be made by

a Board teleconference (if they cannot be made at an in-person meeting).

Finally,

if the electronic voting system is retained for such decisions, it should be

modified to have the voting done in two stages - stage one, lasting, say, 6-8

days, would be for expressing opinions; stage two would be the actual vote.

At

the very least, the Board should not make potentially controversial decisions

like a No-Go on a " no objection " basis!

Garmaise (david.garmaise@...)

is a senior analyst with Aidspan.

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7. ANNOUNCEMENT: UNDP Is Recruiting an International

Consultant

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The

HIV/AIDS Group of the United Nations Development Programme (UNDP) is seeking an

" International Consultant " to work in its New York office starting 3 January 2010. The

consultant will provide support to the dissemination and implementation of the

UNDP's operational plan for the removal of punitive law, policies, practices,

stigma and discrimination. Some of the responsibilities of this consultant

involve the Global Fund directly - for example, the consultant will support a

high-level consultation on increasing the focus on human rights in the

policies, programmes and processes of the Global Fund.

The

deadline for applications is 25 November 2010. More information can be found at

http://jobs.undp.org/cj_view_job.cfm?job_id=20138.

" Reproduced from the Global Fund

Observer Newsletter (www.aidspan.org/gfo), a service of Aidspan. "

Forwarded by:

---------------------------

Yours in Global Concern,

A.SANKAR

Executive

Director- EMPOWER - Professional Civil Society Organisation

Vice Chairman -Initiatives of Health Net (IHN)

Founder and General Secretary - Confederation of

Indian Civil Society Organisation’s (CICSO)

National Convener- National Alliance for Health,

Environment and Rights ( NAFHER)

107J

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TUTICORIN-628

008, TN, INDIA

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91 461 2310151; Mobile: 91 94431 48599: www.empowerindia.org

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