GLOBAL FUND OBSERVER (GFO) NEWSLETTER, a service of Aidspan.

Issue 32 - Monday 20 September 2004. (For formatted web, Word and PDF versions of this and other issues, see www.aidspan.org/gfo/archives/newsletter )

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CONTENTS

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This is a "double issue" of GFO. It contains articles based on three significant presentations about the Global Fund that were made at the Bangkok International AIDS Conference in July. It also has articles on two other topics.

1. NEWS: Global Fund Launches Public Awareness Campaign

The Global Fund has launched a campaign to raise awareness about the Fund. It includes a video that conceptually illustrates disease being confronted by the Global Fund. It does this by showing a street-fighting bully who is eventually knocked flat by an even bigger fighter.

2. COMMENTARY: David and Goliath - PWAs and the Global Fund CCM in Bolivia

by Gracia Violeta Ross Quiroga

The author is a Bolivian woman living with HIV. When she first visited the Global Fund Secretariat, she felt like David facing Goliath. That, she says, is also how she and her fellow PWAs felt when they first dealt with the Bolivian CCM. But they eventually had something of a victory, because PWAs now play a key role as members of a much more effective CCM.

3. COMMENTARY: Multiple Principal Recipients: The Zambian Approach

by Elizabeth Mataka

The author describes how the Zambian HIV grant has four Principal Recipients (PRs), each one dealing with sub-recipients in the sector of society it knows best, yet all cooperating to maximize the chances of success. (This approach has sparked interest around the world, because it overcomes many of the problems encountered by single PRs.)

4. COMMENTARY: A Critical Review of New Funding Mechanisms

by Mabel van Oranje

"If you want to put serious new money into fighting AIDS, where can you get the best bang for your buck? By going bilateral? By choosing the UN route? By using new funding mechanisms? Based on the early evaluations, I would put my money in the Global Fund."

5. ANALYSIS: Global Fund Secretariat Country-by-Country Contact Information

A list is provided of Global Fund contact staff dealing with each country that is eligible for Global Fund grants.

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1. NEWS: Global Fund Launches Public Awareness Campaign

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The Global Fund has launched a campaign in France to raise awareness about the Fund. It will feature advertisements in nearly 40 French magazines and newspapers, on several French television channels, and in the largest network of cinemas in France. By early next year the campaign will extend to Germany, Italy, Japan and the UK. The Fund had previously announced a partnership with VH1, a music channel in the United States, which will produce and air Global Fund public service announcements to an audience of more than 90 million U.S. households.

In France, all of the advertising space has been donated, including $1 million worth of media placements in September alone. In a letter to the Global Fund board, Executive Director Richard Feachem wrote that these initiatives will raise the profile of the Fund beyond the inner circle of stakeholders, arguing that "if we are to ensure sustainable, long-term funding for the Global Fund, we need to ensure that the populations of our main donor countries are aware of the positive impact of their governments' contributions." He went on to describe the media campaigns as "a prime example of private-sector support for the Global Fund."

The media campaign was designed by the Publicis Group, the world's fourth largest communications company, on a pro bono basis. In July of last year Maurice Lévy, Chairman and CEO of Publicis, said that the company had already worked on the campaign for several weeks. He said that to find the right concept of how to present the Global Fund is "not an easy task" if what you want to get is "not tears, but commitment." The company concluded that the best approach should be to come up with "something positive." He added that the company had been working "very hard" on showing that we want to live in a better world. The concept to be illustrated "is not about charity, it is about investing in our future."

Evidently, Publicis ran into difficulties with those plans. It took another year-and-a-quarter before the campaign was ready. And the resulting video that is starting to run on TV and in cinemas is very different from the "positive" concepts that Mr. Levy discussed.

Set in a gritty neighborhood in Glasgow, Scotland, the ad shows a street-fighting bully making trouble wherever he goes. "I love to fight," he says. "The young, the old, the big. Nobody frightens me. Nobody can beat me." But then he meets his match when an even bigger fighter knocks him out cold with a single blow. The screen fades to black, and the words, "The Global Fund," appear, along with - in French, for now - the words "To win a fight, size matters."

The print campaign is less unconventional. Dramatic photographs show objects chosen to symbolize prevention and treatment - a gigantic tube of anti-malaria medicine, along with an equally large capsule and syringe - being carried through difficult ocean, desert and jungle environments by a ship, a helicopter and a truck.

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2. COMMENTARY: David and Goliath - PWAs and the Global Fund CCM in Bolivia

by Gracia Violeta Ross Quiroga

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[Adapted by the author from a presentation she gave on July 14 at the Bangkok International AIDS Conference, at a satellite session entitled, "The Global Fund: How CCMs Can Be More Effective," organized by Aidspan and other NGOs. A translation of this article into Spanish will shortly be posted at www.aidspan.org/gfo/docs/gfo62.pdf.]

I was once invited as a community representative to attend a meeting at the Global Fund (GF) headquarters in Geneva. I entered the building and saw many people working hard. I felt I was looking at a machine with human parts. While in that big building, I felt so small, so insignificant, so lacking in information and skills - I felt hardly qualified to speak to the GF staff person who deals with my country.

Yet I speak English; I was able to attend university; I am middle class, single, without children, and able to travel. Imagine then how people feel if they have HIV and are already sick, if they do not have basic English language skills or basic education, if they have never been in an airplane or been to Europe, if they are poor and isolated. I am sure that when they want to deal with the Global Fund, they feel like David facing Goliath. Yet isn't it the goal of the Global Fund to save the lives of precisely these people?

My aim in using this metaphor is not to highlight a tense relationship with the GF, but to illustrate the conditions faced by PWAs (People Living with HIV/AIDS) who want to get involved in the GF process. Unfortunately, the Global Fund has become a bureaucratic Goliath. And unfortunately, PWAs are still Davids. The happy ending for this story is not the death of the giant, which we certainly do not want. It is that sometimes PWAs do succeed in dealing with the GF giant.

*A Weak Start*

When the Global Fund began to accept Round 1 proposals, few people in Bolivia had heard of the Fund. Many PWAs, even PWA leaders, knew nothing about what was being done in Bolivia about the GF. One reason may be that most of the information was only available in English.

Proposals were written to the Fund almost in secrecy. During Round 1, for example, a Bolivian network of NGOs presented its own proposal to the GF without telling anyone else about the initiative. We only learned about their proposal much later - when this network asked for a seat on the CCM - and fortunately, their proposal was rejected.

As for the CCM, PWAs were only invited to join after we applied pressure.

During the second round, a Bolivian CCM as a national mechanism was created for the first time. Unfortunately, most of its members were from La Paz, the capital.

The GF guidelines suggested that CCM members should belong to already existing networks. But we at the grassroots level suspected that some of the networks claiming to have worked on AIDS were coming only for the money. We said to them, "If you were already working on AIDS, why did we feel lonely for so long?"

At this stage we formed REDBOL, the Bolivian Network of PWAs, but our new network lacked formal legal status as an NGO. This was the principal argument people used to block our participation on the CCM. We were seen as beneficiaries but not as legitimate voices to design and implement the proposal.

Much of Bolivia's Round 2 proposal was written at the last moment; certainly PWA leaders were consulted only at the very end. This situation produced a very weak proposal, which was rejected.

*Strategies for Pressing the CCM and the Government*

After the Round 2 failure, before the buildup to the third round, the Bolivian CCM was open to becoming more inclusive, and invited membership from TB and Malaria organizations, organizations of indigenous people, traditional healers, members of the army, and others.

REDBOL decided at this point to develop a serious advocacy strategy for effective PWA membership of the CCM. And since a principal objective of the Global Fund grants was to save the lives of PWAs, we believed our inclusion was mandatory. This is how we set about achieving our goal:

• Our first task was to learn about the Global Fund. Most of the available information was in English. We turned for help to REDLA, the Latin America Network of PWAs, and ICASO, the International Council of AIDS Service Organizations. (The inputs of Rodrigo Pascal, a member of the "Communities" delegation to the GF board, were especially important for us.) These friends provided us with information in Spanish. They taught us it was our right to be involved. They helped us understand the GF and its principles and goals. They provided technical and practical tools to help us advocate for our participation and to play an active role.

• We then started advocating with the government. We started to put this issue on the national AIDS agenda.

• We wrote a position paper calling for the inclusion of PWAs in the CCM. By this time, our knowledge about the GF was quite good. PWAs across the country developed a unified position related to the GF, and we did not fight each other for access to the funds.

• We were persistent in sending letters denouncing the fact that PWAs were not involved in the CCM and the whole GF process. We kept emailing these letters to national and international networks, even to the GF. These letters were intended to embarrass the CCM and the Bolivian government. They were very effective.

• At that point, the CCM not only excluded PWAs, it excluded most cities and regions outside La Paz, the political capital. We networked across the nation. We had leaders in the three principal cities of Bolivia who were open about their HIV status, and ready to go to the media. We agreed on the key issues and then publicly said, "We demand to be included in the CCM as the national network of PWAs; we demand this, that, etc."

• We also started a personal skills-building process. Using materials from REDLA, we learned how to negotiate, come to a consensus and maintain the dialogue, all critical skills that allowed our leaders to become active CCM members. It was especially important for us to learn how to put a firm line around our "not negotiable issues" for the GF proposal (e.g. access to treatment, support for REDBOL, etc.)

• REDBOL took on the constant role of watchdog. We encouraged all PWAs to read the failed Round 2 proposal which was to be the basis for the Round 3 proposal, and to give their opinions.

• Our strategy was completed by setting up strategic alliances with the government's National Program on STDs and HIV/AIDS, with NGOs, and with key officers of some UN agencies. All of these actors supported our demand to be included more seriously in proposal development.

• At the GF regional meeting in Panama last November, Julio César Aguilera, a PLWA from Bolivia, commented "I am grateful that almost all of the agencies who are here [USAID, PAHO, GTZ, UNAIDS, the World Bank, etc.] are working to help us in Bolivia. But I wonder how it is possible that as yet not even one PLWA in my country has received ARV treatment?"

*A Summary of Victories*

The above actions were very effective.

• Since the time of development of the Round 3 proposal, we have had three national representatives of PWAs on the CCM, one from each of the main cities, up from zero before.

• The REDBOL coordinator is not only a CCM member but also a member of the CCM's executive committee. Even though he lives in Santa Cruz, we successfully negotiated with the CCM to cover his travel expenses to La Paz.

• PWAs in Bolivia are now among the experts on the GF. And it is generally accepted that whenever something is being done related to the GF, PWA representatives must be consulted.

• The Bolivian CCM now uses an election process for choosing members, whereas members were originally appointed.

• The reconstituted Bolivian CCM developed a spirit of unity and harmony, focusing on the fight to develop a successful Round 3 proposal.

• The GF accepted all three proposals (HIV/AIDS, TB and malaria) that Bolivia submitted in Round 3. The GF's Technical Review Panel wrote, "Good Government/NGO partnership. Defense of human rights of PLWHA is a priority."

• Sixty percent of the Bolivian proposal on HIV/AIDS is destined to purchase ARV medication. This was one of the "not negotiable" items of REDBOL. Part of the grant will also support existing networks of PWAs.

• The CCM has become a place where PWAs can sit at the same table with policy makers and other national leaders, talking and negotiating.

• The CCM has become a more transparent mechanism. It has developed a constitution with agreed goals, structure, and responsibilities.

• During a recent political crisis, in which there was an unexpected change of political leaders within Bolivia, the Bolivian CCM managed to keep working with unity and harmony, despite having a new chair.

*Challenges Ahead*

We have had many successes, but we still have a long way to go. We have to analyze how the approved grants will function at the grass roots level. The CCM doesn't yet cover the transportation costs of most of those members who have to travel from around the country to meetings in the capital city. REDBOL still lacks offices of its own and has only a small group of leaders. The CCM has grown too large, including many representatives of organizations with no background in AIDS, TB or malaria. The CCM has yet to fully implement the GIPA principles (Greater Involvement of People Living with HIV/AIDS), and must improve its dissemination of key information to PWAs across the country. The CCM does not have currently any female PWA members. We face political instability in Bolivia, which means the government representatives to the CCM often change, disrupting the CCM's functionality. Lastly, CCM members still sometimes think of the CCM as a governmental institution, and view the desires of the government representative as requirements. We must not forget that the CCM is a mechanism of the country, which includes civil society, not just government.

[Gracia Violeta Ross Quiroga (graciavioleta@yahoo.co.in) is a Bolivian woman living with HIV, a member of the Bolivian Network of PWAs (REDBOL), and a representative to the WHO's 3x5 working group of the Latin American Network of PWAs (REDLA) and of ICW. Prior to her leaving Bolivia for personal reasons, she was a member of the CCM. She thanks Julio César Aguilera, Jorge Herrera, and Daniel Ruiz, her colleagues at REDBOL, for their input into this article.]

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3. COMMENTARY: Multiple Principal Recipients: The Zambian Approach

by Elizabeth Mataka

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[Adapted by the author from a presentation she gave on July 14 at the Bangkok International AIDS Conference, at a satellite session entitled, "The Global Fund: How CCMs Can Be More Effective," organized by Aidspan and other NGOs.]

Zambia, one of the countries hardest hit by the AIDS epidemic, is also very resource constrained. So while the response to the epidemic in Zambia is now well into the second decade, that response has largely remained at the pilot stage. The advent of the Global Fund to Fight AIDS, TB and Malaria was therefore seen as an important opportunity for Zambia to scale up interventions that work.

The Zambian government quickly put in place a Country Coordinating Mechanism (CCM) to begin developing a proposal. From the start, the CCM was representative of all sectors - the church, academic institutions, civil society, government, traditional healers, youth, the business sector and PLWAs. This was achieved in great part because the National AIDS Council (NAC), in existence since late 2000, launched an active and consultative process to aid in the CCM's development. The NAC, which now provides secretarial services to the CCM, wrote to umbrella organizations of the various stakeholders - such as churches, NGOs, and community organizations (CBOs) - asking each to nominate a representative who would speak for their interests at the CCM. Because CCM representatives from each sector were nominated by their own constituency, they received a mandate from the groups they represented. My organization, for example, the Zambia National AIDS Network, held a consensus-building workshop with CBOs and NGOs to fully brief them on the Global Fund process and to get a mandate from them to proceed.

The process of developing each Global Fund proposal in Zambia included all stakeholders. This involvement ensured that the concerns of the different sectors were taken on board. And since people owned the process, they committed themselves and their constituencies to the full implementation of the program. Furthermore, this consultative approach to the development of the proposal meant that the CCM had no difficulty endorsing the proposal for submission to the Global Fund. All five proposals that the Zambian CCM has submitted to the Global Fund (three in Round 1 and two in Round 4) have been approved.

It turned out that developing the Round 1 HIV proposal and getting it endorsed by the CCM was a much simpler task than the steps that lay ahead: ensuring that the funds were speedily, effectively, equitably and transparently moved to where they were needed most, in all sectors - communities, private sector, groups of PLWAs, high-risk groups, the church, government departments, academic institutions, and treatment centers. Bringing together different interest groups, with different approaches and outlooks, proved quite challenging. The process, however, was assisted by an intense level of communication and consultation. Through this process, it became clear that all stakeholders had one common agenda: to have a meaningful impact on the epidemic. The challenge was to find a modus operandi that was acceptable to all.

The first important principle we established was to use indigenous existing structures. The CCM decided that no new structures were to be established for the Global Fund. Rather, existing structures would be examined and, if necessary, strengthened.

Second, civil society was quite strong in advocating that funds destined for civil society programs be received by a civil society organization serving as a Principal Recipient (PR). In Zambia, government and civil society have a long history of working together responding to AIDS, but civil society organizations had concerns that channeling funds through a government bureaucracy might lead to unnecessary delays. We in civil society also believed that the government was not structured to reach very grass roots organizations, while civil society organizations have a direct interface with the local CBOs best positioned to make a contribution in the fight against AIDS. We could easily tailor our programs to reach these grass roots groups.

As we debated how to choose PRs for our Round 1 Global Fund proposal, many options were advanced. The first option was the Ministry of Finance. But this Ministry explained that there were legal restrictions on their issuing checks to civil society directly, unless the civil society groups were already named in the national budget. So funds would have to be channeled through another agency. The excess bureaucracy surrounding this method was obvious to all. Additionally, since this ministry was already overwhelmed with fiscal responsibilities to the nation, it was unlikely to prioritize AIDS, TB and malaria.

The second option was the Central Board of Health under the Ministry of Health. After lengthy discussions, it was agreed that AIDS was not just a health issue, it was a cross-cutting issue with complex ramifications. In this regard, we agreed that the Central Board of Health would be better left to deal with funds directed at treatment and other technical issues in line with their mandate of providing health care, but that it could not reasonably be expected to prioritize socio-economic aspects of the epidemic, such as orphans and vulnerable children.

After debating other options, we finally agreed that it would be feasible and desirable to have more than one PR in Zambia, with each PR using its special advantages to move the much-needed funds in an efficient manner. The CCM's flexibility on this front was facilitated by the long history of Zambian NGOs and CBOs in responding to AIDS. Many of these organizations have successfully attracted bilateral and other external funding, as well as support from the government, for delivering care to orphans and vulnerable children. The Churches Health Association of Zambia already provides half of Zambia's rural health services, supported by a government grant. Given the severity of the epidemic in Zambia, the government is quite open about embracing all of these existing resources.

In the end, the CCM decided to use four existing institutions to disburse the global funds, two from government and two from civil society:

• Central Board of Health (under the Ministry of Health): funds for treatment and other technical health issues.

• Ministry of Finance: funds for government line Ministry programs.

• Churches Health Association of Zambia: funds for faith-based civil society organizations.

• Zambia National AIDS Network: funds for non-faith-based civil society organizations, including private sector work place programs and groups of PLWAs.

Having received this approval, the four PRs had to ensure that they would pass the assessment by the Global Fund's Local Fund Agent. During this proposal development phase, the Zambia National Aids Network (ZNAN) had to acknowledge that it was still a weak institution with very limited capacity and certainly could not pass the assessment. But civil society members of the CCM saw this as an opportunity to build the capacity of an indigenous NGO that would remain in country to coordinate the achievements of Zambian AIDS service organizations, whether funded by the Global Fund or other donors. This concept was successfully sold to bilateral donors such as NORAD, who gave funds for rapid capacity-building in terms of human resources, infrastructure and systems. ZNAN also signed a contract with an international accounting company for continuous financial management capacity-building over one year.