Heart of the Matter
To Date, Global Fund Offers Hype and Hope -- But Little Else -- To Majority of Those in Need
By Richard Stern
"The CCM Catch-22"
The Global Fund offers promises and hope for many, but a view from the field in Latin America and the Caribbean indicates that when it comes to antiretroviral treatment access, the complications are many and the promises offered by the Fund are slow to be fulfilled. Agua Buena's Richard Stern recently prepared this survey of the landscape in the Spanish-speaking Americas. More of his first-hand reporting is available at www.aguabuena.org.
In Ecuador and the Dominican Republic, prolonged internal disputes involving Country Coordinating Mechanisms and Principal Recipients* have meant that even though their proposals were accepted by the Fund in January 2003, the grant agreements had still not been signed as of late November, and thus no money has been received. These countries compounded the problem by deciding to wait for Global Fund money to arrive before starting to purchase antiretrovirals for targeted populations. Thus, ironically, the existence of the Global Fund has actually delayed treatment access in these countries.
There is another problem, somewhat less dramatic, that has occurred in almost every country. NGOs that in the past might have tackled violations of human rights or gaps in treatment access now have to consider whether such activism could cause them to lose access to Global Fund revenue received by their local Country Coordinating Mechanism. (A Country Coordinating Mechanism, or "CCM," is country-level partnership that works in concert with the Global Fund.) It is important to remember that in Latin America, prior to the Global Fund, only very minimal amounts of financial support have been available for civil society through national AIDS programs. The Global Fund's appearing on the scene represents a potential "windfall" of resources, and the dynamics related to advocacy have changed considerably. The key factor here is that most Country Coordinating Mechanisms are, in fact, government controlled, even if that is not the Fund's intention.
The domination of government in Country Coordinating Mechanisms was dramatically illustrated in the Latin American/Caribbean Regional Meeting that the Fund held in Panama in late November. Incredibly, only 8 of 160 participants were people living with HIV (PWHIVs). The Fund had instructed Country Coordinating Mechanisms to make their own selection as to who to bring to the meeting, and only four out of the twenty countries present -- Costa Rica, Bolivia, Colombia and Cuba -- actually included PWHIVs in their delegation.
One of the most interesting moments in the Panama meeting occurred on the final day when nearly a dozen international agencies marched to the podium to present themselves. Among them were USAID, PAHO, GTZ, UNAIDS, the World Bank, the Interamerican Development Bank, UNDP and UNICEF. Many of the agencies made references to the hundreds of millions of dollars they have invested in the AIDS pandemic. After the speakers had concluded their presentations, Julio Cesar Aguilar, a PWHIV from Bolivia, commented "I am grateful that almost all of the agencies on this stage are working to help us in Bolivia. But I wonder how it is possible that as yet not even one PWHIV in my country has received antiretroviral treatment?"
Eighteen months after the Fund began operations, Global Fund money has only led to some 800 to 1,000 people receiving treatment in Latin America and an additional 1,000 in the Caribbean. Most of these are in Honduras and Haiti, which had their proposals approved in Round One, and some are in El Salvador. (Argentina and Chile may also be providing some antiretroviral access with funds provided by the Fund, but antiretroviral access in these two countries was nearly universal even before the Global Fund began to provide monies.)
With the impending arrival of Global Fund money, it seems almost inevitable that there is intense competition and distrust between civil society and government, as well as among NGOs themselves. In two of the countries mentioned above, the fight about who was to be the Principal Recipient was taken by NGOs to the Fund's mid-level staff, and perhaps beyond, and this has resulted in delays which will set the process of actual disbursement of funds back as much as a year. Those who urgently needed antiretrovirals in 2003 will now have to wait until 2004. As many as 25% will not survive.
Another problem is that in some countries, NGOs which represent vulnerable populations such as gay/lesbian/bi/trans people are routinely denied legal registration, yet Country Coordinating Mechanism regulations stipulate that only legally registered NGOs can benefit from Global Fund money. So, because of this Catch 22, these groups -- which have a real ability to reach out to and conduct prevention work among their own populations -- are supplanted by legally registered NGOs that suddenly appear on the scene and have no demonstrated track record in working with vulnerable populations.
Another discouraging factor is that some of the accepted Global Fund proposals in the Latin American region were written by highly capable experts who joined forces with local Country Coordinating Mechanisms only for the purpose of writing the proposal. In these cases, the accepted proposal does not always accurately reflect the country's national AIDS program or its ability to put large amounts of money to good use in AIDS programs. Some proposals reflect mainly the writing and technical skills of the outside consultants who drafted the proposals.
Another issue is that the few civil society representatives on the Country Coordinating Mechanisms often are well intentioned but poorly trained regarding more technical issues of program implementation and medication purchase. Many of the PWHIV representatives come from backgrounds where they simply have not been trained in the necessary areas. This puts them at a tremendous disadvantage when facing government AIDS bureaucrats who may dominate decision-making processes in areas to do with antiretroviral access and other "technical" issues.
The only feasible solution to the problems elaborated above would be greater active participation of the Global Fund in Country Coordinating Mechanism activities and program implementation. The Fund is reluctant to do this because it has limited staff and it wants local capacity to develop and national AIDS programs to become self-sufficient. One possibility would be for this to happen in phases with, at first, much more support from trained experts whom the Fund could employ after a proposal has been approved.
To suddenly present a previously impoverished and not particularly well-trained AIDS program with the prospect of millions of dollars is certainly well intentioned but can sometimes lead to all kinds of unforeseen problems, ranging from inadequate infrastructure to rampant manipulation and corruption. People living with HIV/AIDS need treatment today, not in a year or two. But without more active guidance and hands on participation from the Fund, situations that are destructive and lead to long delays in treatment access will undoubtedly continue to occur.
* Local entities, nominated by Country Coordinating Mechanism and confirmed by Global Fund, who are to be legally responsible for the dispersal of funds and implementation of the program.
Richard Stern (firstname.lastname@example.org) is Director of Agua Buena Human Rights Association, based in San José, Costa Rica. He travels widely in Latin America working with community groups on HIV/AIDS treatment issues.
The 0.8% Solution
Eighteen months after its launch, the Global Fund has led to some 800 to 1,000 people receiving antiretrovirals in Latin America and an additional 1,000 in the Caribbean -- of the estimated 250,000 currently in need of treatment.
Source: Richard Stern (aguabuena.org), 1961-2003