GLOBAL FUND OBSERVER (GFO), an independent newsletter about the Global Fund provided by Aidspan to over 8,000 subscribers in 170 countries.
Issue 120: 16 April 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: Concerns Raised About Possible Changes to Eligibility and Prioritisation Criteria
Activists in Latin America and the Caribbean have expressed concern that the Global Fund may make changes to its eligibility and prioritisation criteria that may disadvantage lower- and upper-middle-income countries, including many in the LAC region.
2. NEWS: Opportunity to Reprogramme Grants to Improve PMTCT Treatment
The Global Fund is working with 20 countries in sub-Saharan Africa to assess the possibility of reprogramming existing Global Fund grants to allow for a switch from the use of single dose nevirapine to more effective dual or triple ARV therapy for PMTCT.
3. NEWS: Analysis of Round 8 Proposals Finds Few with Strong Gender Components
Only 2.6 percent of the 76 Round 8 HIV/AIDS proposals were gender transformative with respect to issues facing women and girls, according to a report prepared by the Global Fund.
4. NEWS: Report Provides Data on Outcomes of Ukraine HIV Grant
As of 31 March 2008, the recently completed Round 1 grant had provided prevention services to 214,103 people who inject drugs. This is one of the results described in a report released by the International HIV/AIDS Alliance. The grant exceeded the vast majority of its targets.
5. NEWS: Report Documents Challenges Facing Applicants and Implementers
Despite the fact that many agencies are providing technical assistance in the region, countries in South-East Asia face a wide range of challenges in applying for and implementing Global Fund grants.
6. NEWS: Global Fund Launches CCM Newsletter
The first edition of the newsletter features several articles on the CCM's role in grant oversight.
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1. NEWS: Concerns Raised About Possible Changes to Eligibility and Prioritisation Criteria
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Activists in Latin America and the Caribbean (LAC) have expressed concern that the Global Fund may make changes to its eligibility and prioritisation criteria that may disadvantage lower-middle-income and upper-middle-income countries (LMIC/UMIC), including many in the LAC region.
Eligibility criteria are used to determine which countries are eligible to apply for funding from the Global Fund. Prioritisation criteria are used to rank proposals recommending for funding when there is not enough money to fund all such proposals.
Concerns about the impact of possible changes to the eligibility criteria stem from discussions at the Global Fund replenishment meeting held on 24-25 March 2010 in The Hague. At that meeting, participants examined a report produced by the Global Fund Secretariat on domestic financing for health in Africa and in non-African LMIC/UMIC countries.
The report, which is entitled, "Trends in Developmental Assistance and Domestic Financing for Health in Implementing Countries," revealed that, collectively, African countries remain far short of meeting their commitment in the 2001 Abuja Declaration to allocate 15% of their national budgets to health care. Six countries have either met or exceeded the 15% target. However, for all 52 countries combined, the average general government expenditure on health as a percentage of total government expenditure rose only marginally from 8.8% in 2001 to 9.0% in 2007. The paper also showed that in LMIC/UMIC countries, national health expenditure is for the most part domestically financed, and that contributions from external sources are complementary or marginal.
Shortly after the replenishment meeting, Friends of the Global Fund, Latin America and the Caribbean (Friends-LAC) released a paper entitled "The Point of No Return," which referred to the Global Fund report and said, "These findings gave rise to different interpretations during the meeting. There were those who highlighted the importance of the Global Fund to act as a catalyst for specific interventions in LMIC/UMIC countries, which would not be covered by domestic sources.... However, donor voices could also be heard, arguing that, in light of the scarcity of global resources, the Global Fund should no longer finance LMIC/UMIC countries."
The Global Fund Board is scheduled to review the current eligibility criteria at its meeting in December 2010.
Concerns about the impact of possible changes to the prioritisation criteria stem from the fact that the Global Fund is expected to adopt new prioritisation criteria for Round 10 at its upcoming meeting in Geneva, Switzerland on 28-30 April 2010. The existing criteria incorporate a two-step process, whereby proposals are first classified on the basis of technical merit (as decided by the TRP), and are then given a point-rating based on the country's poverty level and disease burden. Under the existing criteria, technical merit is given by far the most weight.
It is not known what recommendation will be submitted to the Board for consideration at its April Board meeting. At its last meeting in November 2009, the Board was presented with a recommendation for prioritisation for Round 9 that called for a ranking system based on points, with technical merit accounting for 30% of the points, poverty level 40%, and disease burden 40%. However, the Board decided to stick with the current prioritisation criteria for Round 9, and said that further discussions were required (for Round 10 and beyond).
Up to now, the prioritisation criteria have only been used to decide when, not if, proposals recommended by the TRP will be funded. For example, in both Rounds 8 and 9, formal approval of some recommended proposals was delayed for up to several months because there was not enough money. But all of these proposals were eventually funded. However, in the current resource-constrained environment, it is possible that not all TRP-recommended proposals for Round 10 and for other future rounds will secure funding. If this happens, then the prioritisation criteria would become (de facto) eligibility criteria.
In its paper, Friends-LAC says, "This year, the Global Fund's Board will approve a new prioritisation model and country eligibility criteria will be reviewed. Unless we speak out loudly and clearly, those countries (much of Asia and Latin America) that are locally investing in health will once again be penalised."
In a separate paper, entitled "Latin America and the Caribbean Must Not Be Sent to the Back of the Queue Again," Friends-LAC urged the Global Fund to ensure "that the prioritisation model does not disadvantage Latin America and the Caribbean. Applications must continue to be considered first and foremost on the basis of their technical merit."
In an email message sent to GFO and others on 31 March 2010, Gracia Violeta Ross, National Chair of the Bolivian Network of People Living with HIV/AIDS (REDBOL), said that if poverty level and disease burden become the main criteria for deciding whether a good proposal gets funded, or is eligible for funding, this will be very detrimental to prevention programming. According to Ross, the Global Fund would be perpetuating the bad practices of development agencies – i.e., focusing on an emergency response instead of focusing on preventing infections and on the underlying causes of the epidemics. Ross also said that if poverty level and disease burden are the main criteria, this could result in a perverse situation whereby some countries let the epidemic grow until the point at which they can qualify for grants.
Friends of the Global Fund, Latin America and the Caribbean (Friends-LAC) is a regional initiative which works to mobilise strategic political and financial support for the fight against AIDS, TB and malaria. The following are all Friends-LAC documents:
"Trends in Developmental Assistance and Domestic Financing for Health in Implementing Countries," March 2010, produced by the Global Fund, is available in English at www.theglobalfund.org/en/replenishment/hague/documents.'
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2. NEWS: Opportunity to Reprogramme Grants to Improve PMTCT Treatment
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The Global Fund Secretariat is working with 20 countries in sub-Saharan Africa to assess the possibility of reprogramming existing Global Fund grants to allow for a switch from the use of single dose nevirapine to more effective dual or triple ARV therapy for the prevention of mother-to-child transmission (PMTCT).
The countries are Angola, Botswana, Burundi, Cameroon, Côte d'Ivoire, the Democratic Republic of Congo (DRC), Ethiopia, Ghana, Kenya, Lesotho, Mozambique, Malawi, Namibia, Nigeria, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe. (Other countries may be added later; a similar initiative is already underway in India.)
There are several factors that have to be considered to determine whether reprogramming is feasible. These include the ability to free up some money in other parts of the grant budgets (e.g., if a particular area is under spent), and whether there already is a PMTCT-related service delivery area (SDA) in the existing programmes.
Opportunities to reprogramme a grant could theoretically come any time, but they are usually linked to milestones in grant implementation – e.g., the signing of a new grant, Phase 2 renewal, and consolidation to a single stream of funding.
The Secretariat is preparing a guidance sheet on this topic. The guidance sheet will include a list of preferred indicators for PMTCT, which will help ensure some consistency across programmes. UNAIDS, UNICEF and WHO are assisting the 20 countries to develop a reprogramming request, and to choose the right strategies for improving the quality and the scale of their PMTCT programmes.
This initiative stems from a decision by the Global Fund Board at its 19th meeting in May 2009, in which the Board requested the Secretariat to "conduct a review of the portfolio to identify paediatric HIV high burden countries with low PMTCT and paediatric HIV care, support, and treatment coverage rates and prepare options to use available mechanisms to accelerate transitions to more efficacious ARV regimens for effective PMTCT strategies...." In the same decision, the Board also urges CCMs and Principal Recipients to consider reprogramming existing grants accordingly.
This is part of a broader strategy on "re-defining the PMTCT service delivery area." The Secretariat will work with technical partners to develop a comprehensive PMTCT package; and will work with the Technical Review Panel (TRP) to translate this package into minimum standards for the review of new proposals, starting with Round 10. The strategy also calls for the development of an advocacy plan to mobilise CCMs, governments, NGOs and others to prioritise optimal PMTCT delivery.
This article is based on information obtained from the Global Fund Secretariat, and on the contents of a slide presentation on "Switching from Monotherapy and Scaling Up Combination Treatment for PMTCT – Presentation to Regional and Technical Teams." The presentation, which was given in Lilongwe, Malawi in December 2009, is available at www.theglobalfund.org/en/regionalmeetings/sa/malawi2009 (click on "PMTCT"). The Board decision cited in this article is part of a broader decision entitled "Enhancing the Global Fund's Response to HIV/AIDS." The text of this decision is available at www.theglobalfund.org/en/board/decisions (look for "19th meeting").
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3. NEWS: Analysis of Round 8 Proposals Finds Few with Strong Gender Components
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Only 2.6 percent of the 76 Round 8 HIV/AIDS proposals submitted for funding were gender transformative with respect to issues facing women and girls. Another 17.1 percent were gender sensitive, while 80.3 percent were gender neutral. These are among the findings of a report prepared by the Global Fund Secretariat, entitled "Gender Analysis of Round 8 HIV/AIDS Proposals."
The Secretariat defined "gender transformative" as "Goals and objectives attempt to re-define women's and men's gender roles and relations." It defined "gender sensitive" as "Goals and objectives attempt to redress existing gender inequalities"; and "gender neutral" as "Goals and objectives do not reinforce existing gender inequalities."
The report also examined gender sensitivity with respect to men who have sex with men (MSM) and other sexual minorities. In this regard, none of the proposals were classified as gender transformative; 10.5 percent were classified as gender sensitive and 89.5 percent as gender neutral.
In its analysis, the Secretariat examined proposed interventions under nine broad categories: behaviour change communication (BCC), prevention services, supportive environment, treatment, health systems strengthening (HSS), care, female condom distribution, harm reduction, and social change communication. Just under half of the proposals had at least one intervention category that was deemed to be gender responsive (i.e., either gender transformative or gender sensitive) – an improvement over previous rounds of funding. Gender responsive interventions were most often found in three intervention categories: harm reduction, supportive environment and prevention services.
A proposal from Somalia was the only gender transformative proposal recommended
for funding. It was written from the perspective that gender inequality is a fundamental underlying factor fuelling the HIV epidemic. The proposal documented the constellation of factors that place women and girls at increased risk of HIV infection, including socio-economic and cultural vulnerability, sexual and gender-based violence and a failure to define and enforce the rights of women and children.
The report said that two proposals classified as gender sensitive, from Iran and Mozambique, "did an outstanding job documenting the range and interaction of factors that contribute to the inequality of women and girls and the mechanisms of their increased HIV/AIDS risk. However, the proposals as written were unable to translate a comprehensive understanding of the depth of gender issues into an approach that could be deemed gender transformative."
Iran's proposal focused on comprehensive harm reduction initiatives that included sexual health for women who inject drugs, while the proposal from Mozambique took a more global approach, aiming to change public opinion about factors that place women at risk, including gender-based violence, inheritance rights and income generating opportunities.
According to the report, 28 percent of the proposals stated that data disaggregated by sex would be collected.
Of the four proposals classified as gender sensitive with respect to MSM and sexual minorities, those from Belarus and Thailand highlighted the increasing HIV prevalence documented among MSM and the underlying social and gender inequalities faced by MSM in their access to prevention, treatment and care, as well as the high levels of stigma faced by this population. The application from Belarus proposed using the Internet to recruit and educate MSM. The proposal from Thailand recognised MSM as the fastest growing population of HIV-infected individuals and proposed interventions to target gender-based violence.
The Secretariat noted that discussion of gender issues was often confined to one section of the Round 8 proposal form (Section 4.5.4: Enhancing gender and social inequalities) and that the gender analysis in that section did not carry over to the rest of the proposal. Some applicants used the section to document the problems faced by women and girls without proposing any type of interventions, while others denied the existence of gender inequalities in their country or regional context.
The report concluded:
"Although many of the applicants are not yet successful in terms of linking intervention categories to gender issues or in recognizing gender responsive potential, the larger range of proposed intervention categories nevertheless represents an important step forward in terms of HIV programming. In particular, a notable expansion of the number of proposals that included structural/supportive environment interventions to address underlying societal contributions to the HIV epidemic was observed. Future technical assistance should be provided to assist applicants to make tangible and feasible linkages between structural interventions and measurable gender responsive indicators with the goal of increasing social and gender equity."
The report, "Gender Analysis of Round 8 HIV/AIDS Proposals," is available in English at www.theglobalfund.org/documents/rounds/9/CP_Analysis_R8_Gender%20Responsiveness_en.pdf.
Copies of individual proposals for all rounds of funding are available by going to the Global Fund home page at www.theglobalfund.org and selecting a country from the drop-down list under "Grant Portfolio."
Aidspan has recently released a report on "Key Strengths of Rounds 8 and 9 Proposals to the Global Fund." It provides several examples of Round 9 proposals with a strong gender component. The report is available at www.aidspan.org/aidspanpublications.
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4. NEWS: Report Provides Data on Outcomes of Ukraine HIV Grant
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As of 31 March 2008, a recently completed Round 1 Global Fund grant in Ukraine had provided prevention services to 214,103 people who inject drugs. By the end of September 2008, 6,070 people, including 911 children, had received antiretroviral therapy (ART). And, in 2008, 80% of pregnant women living with HIV had received treatment to prevent mother-to-child transmission, up from 35% in 2003. The grant exceeded the vast majority of its targets.
This information was contained in a report released in September 2009 by the International HIV/AIDS Alliance. The grant, which cost $98 million over five years, supported programmes that involved the rapid scale-up of ART, a comprehensive package of care, support and prevention services for most-at-risk populations, and the roll-out of substitution maintenance therapy.
The Global Fund grant formed the major part of the national response to HIV and AIDS in the Ukraine. During the period of the grant, the number of new HIV cases per 100,000 tests decreased from 632.8 in 2006 to 590.2 in 2008; and the AIDS mortality growth rate dropped from 38% to 8% (between 2004 and 2008).
The report, "Civil Society Leads National Response – Final Report: Overcoming the HIV/AIDS Epidemic in Ukraine, Funded by the Global Fund (2004-2009)," also describes the experiences of the International HIV/AIDS Alliance as principal recipient (PR) of the grant, and outlines the lessons learned from the experience.
In 2002, the Global Fund approved a proposal for CCM Ukraine for a programme called "Overcoming HIV/AIDS Epidemics in Ukraine." In January 2003, the Fund awarded grants to three PRs, the Ukrainian Ministry of Health, a charitable organisation called the Ukrainian Fund to Fight HIV Infection and AIDS, and the United Nations Development Programme (UNDP). The International HIV/AIDS Alliance, through its country office, Alliance Ukraine, served as a sub-recipient (SR) under two of the PRs.
A year later, the Global Fund suspended the grants amid concerns about how they were being managed. Alliance Ukraine was selected as the new PR for all three grants (see GFO 18, available at www.aidspan.org/gfo). (The three grants were eventually rolled into one.) The Alliance thus became one of the first civil-society organisations to become a sole PR for a grant. During the course of implementing the grant, Alliance Ukraine went from a country office of the Alliance to being an independent organisation, but part of the Alliance family.
According to the report, one of the Alliance's major contributions to the grant was to strengthen civil society. The Alliance supported the development of the All-Ukrainian Network of People Living with HIV/AIDS (PLHA Network) and 150 new and existing NGOs.
Over the course of the grant, the Alliance conducted regular stakeholder meetings, involved vulnerable communities, and implemented transparent programmes to develop workplans and budgets. According to the report, this has led to a fundamental shift in the national response to the HIV and AIDS epidemic and in wider society, "creating a culture of increased openness, accountability and confidence."
Ukraine subsequently secured a Round 6 HIV grant from the Global Fund to finance another programme for 2007-2012. For this grant, the CCM selected Alliance Ukraine and the PLHA Network as co-PRs.
The report contains several case studies describing innovative approaches used to implement key activities of the Round 1 grant. The topics covered include the rapid scale-up of ART; getting services to vulnerable communities; using advocacy to remove barriers to substitution maintenance therapy; and providing life skills-based education in Ukrainian schools. The report also describes how the grant helped establish a national monitoring and evaluation system for Ukraine; and how procurement systems were set up to deliver better drugs more cheaply.
The report is available on the website of the International HIV/AIDS Alliance at www.aidsalliance.org/publication-search.aspx (select "Global Fund" under the heading "Subject Matter").
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5. NEWS: Report Documents Challenges Facing Applicants and Implementers
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Despite the fact that many agencies are providing technical assistance (TA) in the region, countries in South-East Asia face a wide range of significant challenges in applying for and implementing Global Fund grants. Some of the challenges originate from Global Fund processes and systems. Others are specific to individual countries.
These are the main findings of a reported prepared by the South-East Asia Regional Office (SEARO) of the World Health Organisation (WHO). The report, "South-East Asia Region Country Experiences in Global Fund Implementation and Impact of WHO Support: A Review and Assessment," was released in April 2008, but came to Aidspan's attention only recently.
The WHO defines South-East Asia as including Bangladesh, Bhutan, Democratic People's Republic of Korea (North Korea), India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste. All but North Korea and Myanmar participated in a survey conducted by SEARO. The report is based on the results of the survey.
In each country, a survey questionnaire was completed by personnel from WHO country offices, CCM chairs, PRs and country or Ministry of Health "focal points."
People from seven of the nine countries surveyed said that the Global Fund's forms were difficult to fill out. Some of the adjectives used to describe the forms were "overly complex," "labour-intensive" and "time-consuming." Many people complained that Global Fund requirements are constantly changing.
Most of the people surveyed said that communication and collaboration with local fund agents (LFAs) have been difficult, due to LFAs' "limited understanding of programmatic realities."
With respect to challenges that originate in-country, survey respondents cited a lack of capacity in a number of project management areas, notably proposal development, workplan development, reporting, data analysis, and management. Respondents also said that PRs and SRs often lack expertise in key technical areas, such as procurement and supply management, development of treatment guidelines, and human resources training.
The WHO has been providing TA in a number of areas, including proposal writing, advocacy and negotiation, grant implementation, monitoring and evaluation, and preparing for Phase 2 renewal. Survey respondents were generally satisfied with the TA provided, particularly in the areas of proposal development and Phase 2 renewal.
"South-East Asia Region Country Experiences in Global Fund Implementation and Impact of WHO Support: A Review and Assessment," is available at www.searo.who.int/LinkFiles/CDS_HTM-01.pdf.
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6. NEWS: Global Fund Launches CCM Newsletter
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The Global Fund Secretariat has released its first CCM Newsletter. The 4-pages newsletter features several articles on the CCM's role in grant oversight. It also contains a small article on the Global Fund's CCM funding policy.
In a message on the front page of the newsletter, Global Fund Executive Director Michel Kazatchkine says that the newsletter "provides a new vehicle through which CCM members can share lessons learned and best practices with their counterparts in countries around the world. Each newsletter
will address a specific theme and will include diverse voices and perspectives from CCM members and other Global Fund partners and stakeholders."
The Global Fund plans to issue the newsletter quarterly. The next issue will focus on the grant management dashboard, a new tool from the Fund that assists with grant oversight. That issue will also contain more information on the CCM funding policy and an article on supervision of sub-recipients.
Copies of the CCM Newsletter are available at www.theglobalfund.org/es/ccm. Currently, only the English language version is posted. The Global Fund Secretariat says that versions in the other five UN languages will be posted shortly.
"Reproduced from the Global Fund Observer Newsletter (www.aidspan.org/gfo), a service of Aidspan."
Forwarded by:
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Yours in Global Concern,
A.SANKAR
Executive Director- EMPOWER - Professional Civil Society Organisation
Vice Chairman -Initiatives of HIV/AIDS Net (IHN)
Founder and General Secretary - Confederation of Indian Civil Society Organisation's (CICSO)
National Convener- National Alliance for Health, Environment and Rights ( NAFHER)
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