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

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Dear Friends,

It seems very probable that many of the points suggested below are

applicable to preparation of Round 8 grants, not only in Latin America, but also

in India.

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

Proposals in Latin America

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


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


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


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


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


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


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


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


It is important to learn lessons from GFATM projects that began four or five

years ago. Even as some approaches have failed, or fallen short, others have

been successful. It is critical that evaluations of past interventions focused

on treatment access be looked at carefully. Those which have been successful in

a given country can be repeated and even expanded upon where appropriate. Many

Components of previously approved projects have already been evaluated and it is

important that those who are writing the Round 8 proposals take these

evaluations into account.

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


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.


Agua Buena Human Rights Asociation

San , Costa Rica


Tel/Fax +506-280-3548

e-mail: <rastern@...>

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