Fix the global fund: Sign on letter

To: Board Members of the Global Fund the Fight AIDS, Tuberculosis and
Malaria

and Secretariat Leadership, the Global Fund the Fight AIDS, Tuberculosis and
Malaria 

 
We, the undersigned, represent organizations that are advocating urgently
for HIV treatment scale up in developing countries around the world. We
request that you use the 10th Board Meeting of the Global Fund to Fight
AIDS, Tuberculosis and Malaria, April 21-22 in Geneva, to address an ongoing
crisis that is undermining treatment scale up efforts and that is
undermining the legitimacy of the Global Fund.

 
Significant, avoidable delays in the implementation of Global Fund financed
HIV treatment programs have meant that people are dying unnecessarily, while
millions of dollars are not being spent saving lives--money that has been
committed is sitting, unspent, either in the banks of Principal Recipients
(PRs) or in the banks of the Global Fund trustee.

 
For example in India, a country with one of the largest HIV epidemics in the
world, despite Global Fund 2-year commitments for HIV alone totaling
$51,946,000 and approximately $5,543,000 already disbursed, no Global Fund
money has been spent on antiretroviral treatment. This is unacceptable. In
Guatemala, a Round 3 Global Fund grant including a treatment scale-up
component still has not purchased a single antiretroviral, although
$1,532,478 of the 2-year, $8,423,807 budget has already been disbursed. In
Nicaragua as of December 2004 only $1,639,136 has been disbursed for that
Round 2 HIV grant, approved in January 2003.  Based on available estimates, 

that disbursed money has resulted in only 75 HIV positive people with access to treatment.

Other countries are experiencing similar situations. The Global Fund was
created in large part because of global public outcry that millions were
dying without access to HIV treatment. But in many countries the Global Fund
has done little to fast-track and prioritize HIV treatment access.

There are various reasons for disbursement delays. In some cases, they are
related to ineffective in-country bureaucracies and corruption, coupled with
a lack of commitment to treatment scale up and a disregard for the lives of
people with HIV. In other cases, policies of the Secretariat and/or the
Global Fund Board have resulted in or contributed to these delays, in part
by creating multiple entities with insufficient mechanisms for transparency,
accountability, and coordination between them.

 
The Global Fund does not implement grants. But without a focus on solving
problems that are blocking grant implementation by taking proactive steps in
countries, delays will continue, people will die unnecessarily, and the
Global Fund¹s results will suffer. Identifying and fixing the problems that
have led to significant, life-threatening disbursement delays must become an
immediate priority for the Global Fund Secretariat, its Board, and the
technical experts and agencies that work with the Global Fund.

We recommend that the Global Fund and its supporters to take the following
urgent next steps: 

1. Immediately implement the overdue early-warning system and begin
reporting publicly about disbursement problems. Richard Feachem, in his
report to the 9th Board Meeting, stated that an early warning system,
announced in June 2004, would be operational by early 2005. The Secretariat
has failed to meet this deadline. A public, transparent early warning system
meant to trigger increased attention from the Secretariat and others to
grants before insurmountable problems develop is critical. It still is not
in place, almost one year after the initial announcement. The Secretariat
must prioritize implementation of this long overdue system, and address
problem grants as emergencies, with the active engagement of grassroots
networks of people living with HIV, technical partners and other allies.

 
The Secretariat should be reporting regularly about grants that are
progressing slowly with a diagnosis of possible causes for lack of progress,
information about what steps are being taken to address the problems, and
who is taking those steps. This information is vital to civil society groups
who are working in their countries for the appropriate and accountable
disbursement of Global Fund money, and have limited or no access to this
information. Furthermore, the Global Fund must act on its Board-mandated
obligation to facilitate the provision of technical assistance and support
in a ³timely and coordinated fashion² and should report in detail to the
Board regarding these efforts.

 
2. Take early action in response to sub-standard Principal Recipients (PRs).
Preliminary analysis shows that civil society PRs implement Global Fund
grants faster than government PRs. When PRs are slow in disbursing funds for
treatment scale up, they should be immediately linked with technical experts
that can help build and strengthen their capacity to disburse funds. They
should be penalized if they continue to disburse funds slowly;
non-disbursement of funds should trigger a change in PR. The Global Fund
should develop requirements for a the addition of a civil society PR to be
³twinned² to non-civil society PRs that have been identified by the Global
Fund to be at risk of poor performance.
 

3. Dedicate a proportion of qualified Global Fund operations staff for
time-limited placements in key countries in their portfolios, to anticipate
and facilitate the resolution of significant problems. This is particularly
important in large countries, and in countries with major treatment scale up
challenges and a track record of poor performance in key indicators, such as
community mobilization necessary for successful HIV treatment program
implementation. 

 
In cooperation with people with HIV, technical partners, and other experts,
the Global Fund should also facilitate and support collaboration between
grant recipients through in developing and sharing best practices for
anticipating and overcoming common problems faced by Global Fund grantees
that waste precious time, such as in the development of Global Fund
Procurement Supply Management (PSM) plans.

4. Correct for the small amount of requests for funding for antiretroviral
treatment through the Phase 2 renewal process. Many HIV grants awarded in
rounds 1-3 do not contain substantive treatment scale up components, as a
result of lack of technical assistance during the time of grant request
preparation, lack of government support for treatment scale up, pressure in
CCMs not to prioritize treatment scale up, or other factors. Such Global
Fund grants are not meeting evolving needs in country and should be
evaluated during the Phase 2 renewal process for appropriate grant
reprogramming to include fast-tracked treatment scale up projects.

5. Commission a study to measure the quality of existing Global Fund
financed treatment projects and report back to the 11th Board Meeting.
Global Fund financed HIV treatment projects that require or appear to
require ³user fees² are already dissuading the poorest and those most in
need from gaining access to care. HIV treatment and care, including
diagnostic and monitoring tests associated with treatment, should be the
free at point of service as a matter of best practice. The Global Fund must
see that these and other fundamental implementation issues are addressed, in
order to ensure that clinical outcomes are as good as possible, and
treatment reaches as many people as possible.

 
The Global Fund claims that, as a country-driven process and as a funding
mechanism that is not an implementing agency, the Global Fund does not have
the mandate to address these problems. This is untrue. The Global Fund must
do more to ensure that avoidable problems are anticipated and addressed so
money can be spent as quickly as possible, and lives saved.

According to the Secretariat¹s own accounts, HIV/AIDS grants have been more
difficult to implement than other grants. We are demanding action and
leadership in response to our grave concern; our lives and the health of our
communities is at stake--along with the life of the Global Fund. The Global
Fund will fail if it continues to ignore the obstacles that are contributing
to avoidable, and lethal, delays in treatment scale up.

Sincerely,

list in formation

Agua Buena Human Rights Association, Costa Rica
Health GAP, USA
Global AIDS Alliance, USA