Latin American and Caribbean (LAC) activists have been sounding the alarm for several years about what they perceive as systematic neglect of the region by the Global Fund. “We are the victims of our successes,” they say to highlight the fact that the Global Fund’s de-prioritization of the region is not a by-product of poor performance but rather a consequence of the current political climate.
Several countries in the region have been successful in bringing down infection and mortality rates for the three diseases – but these successes obscure the disparities, gaping inequality and heterogeneity of the region. Worldwide, the Caribbean is the region with the second highest prevalence of HIV after sub-Saharan Africa. The island of Hispaniola, which houses Haiti and the Dominican Republic, is battling a rising epidemic of malaria and, according to the Stop TB Partnership, multi-drug resistant TB has been on the rise in Peru since 2009.
The fires are still burning. Nevertheless, overseas development assistance flows to the region are trending downwards. Many wealthier nations (the Global Fund donors) refuse to pay their fair share into the international cooperation bucket, citing rising per capita incomes as evidence of the ability of recipient countries to mobilize domestic resources to allocate to their own development.
As it stands, in LAC the Global Fund has an active portfolio of grants to 18 countries and eight regional grants. Although this may seem significant, the Results Report 2017 shows that these grants represent only 4% of the global portfolio. By way of comparison, the Global Fund spends 65% of its money in sub-Saharan Africa, 19% in Asia and the Pacific, 8% in the Middle East and North Africa, and 4% in Eastern Europe and Central Asia.
In recent years, LAC has enjoyed, generally speaking, an increase in per capita income and a push towards democratic consolidation. That said, the resulting “upgrade” to upper-middle-income and high-income status (as defined by the World Bank) has not always translated to better quality of, or access to, health care – especially for the poorest and most marginalized. There have been countless reports, think pieces, alerts and impassioned speeches calling attention to the need to re-evaluate the Global Fund’s approach to sustainability and eligibility in the region and across the portfolio, but they seem to have largely fallen on deaf ears. This is not to say that there has not been a flurry of activities around these issues. To the contrary, we have seen the Global Fund create a number of laudable initiatives, assessment tools and workshops to help countries cope with the new normal – but without signaling a genuine openness to challenge the status quo.
An unwavering stance on Venezuela
Probably the biggest elephant in the room is the Global Fund’s response, or lack thereof, to the crisis in Venezuela, whose AIDS program, a former benchmark for the region, lies in ruin. While the Board has expressed “continued concern about the resurgence of malaria, shortages of critical commodities for HIV and TB, and broader health crisis in Venezuela and its impact on the region,” it has thus far refused to engage directly, citing Venezuela’s status as an upper-middle-income country. This, despite the fact that the NGO rule sets a precedent for funding upper-middle-income countries that fall outside of the eligibility requirements. The NGO rule is a policy exception which allows the Global Fund to channel money directly to civil society in cases where the services requested in the funding application are not being provided because of political barriers.
Whether the NGO rule would apply “as is” to the Venezuela case is certainly debatable given how disputed both official GDP and disease burden figures are, but the point is that the Global Fund has given money to countries with hostile and problematic governments before and the Board could vote to do it again. The Global Fund has alluded to the possibility of a regional level initiative to address the crisis in Venezuela, but to date nothing concrete has been announced. The Global Fund needs to act now. People should not suffer and die simply because of political maneuvering.
(See also separate article on Venezuela.)
Countries in the region operate in three of the Global Fund’s four official languages: English, French and Spanish. Advocates note the paucity of official documents available in Spanish and French. Participants at meetings where the Global Fund has made presentations often notice that slides are only partially translated with crucial labels to graphs remaining in English. A cursory perusal of the Global Fund website finds that board meeting reports and decision points are only available in English, as are a number of key documents and publications. For example, the Global Fund Strategy 2017-2022 and the 2017-2019 Funding Cycle Overview can only be downloaded in English.
Nevertheless, there have been strides made to improve stakeholders’ access to key information about the Global Fund. Many policy documents are eventually available in French and Spanish, fund portfolio managers are often conversant in multiple languages, and countries have the option to submit their applications in any of the official languages. Additionally, the Global Fund has introduced Regional Platforms for Communication and Coordination which, as part of the Community, Rights and Gender Special Initiative, are intended to enhance civil society’s and community groups’ knowledge of Global Fund policies and procedures and of how to access technical assistance and support. The Latin American and Caribbean Platform hosts a resource library which aims to ensure that strategic information is translated and widely disseminated. While the platforms are a welcome addition, the Global Fund can and should do better at ensuring that key documents are translated fully and in a timely manner.
Inclusion in pilots and studies
At any given time, the Global Fund is rolling out a number of country-level pilot projects and studies. These are often implemented in sub-Saharan Africa or Asia and the Pacific, which combined account for 84% of the Fund’s portfolio. At present, the Technical Evaluation Reference Group (TERG) is currently rolling out three studies: prospective country evaluations in eight countries; a review of the implementation of gender-responsive programming in five countries; and a review of the reasons for under-utilization of investments in improving country data systems in five countries. Only the first study includes a country in the LAC region: Guatemala.
To be sure, the Global Fund has to prioritize and with the majority of the portfolio concentrated in sub-Saharan Africa, it makes sense for that region to feature prominently on the agenda. However, the more diversity that is incorporated into the design of a pilot or the implementation of a study, the better the insight that can be gleaned – particularly for an organization that operates globally. And while quantity is an issue, so is quality. Historically, African and Asian countries often have extensive data collection via in person, site visits while key informants from LAC are often relegated to phone interviews – further fueling the perception of neglect.
It is worth noting that in 2017, the Global Fund has involved the region in the development and piloting of a transition readiness assessment tool. The purpose of the tool is to provide valuable input for transition planning in countries that are receiving a final Global Fund grant for a disease or are facing significant reductions in their allocation over the next period. Given that a significant proportion of the countries that will be applying for transition funding are from the LAC region, it makes sense that the approach is tested out in that region. However, transition is by far not the only issue of immediate relevance to the region, and more efforts should be made to ensure that LAC is better included across the board.
In essence, there is a clear indication that the Global Fund could and should be doing more in the region. To be fair, it is a logistically complex place to work. It includes a number of small island nations that are difficult to travel to and from, both internally and to/from Geneva, and it creates the need to simultaneously operate in multiple languages – especially Spanish, which is not widely spoken at the Secretariat compared to English and French. While no one is denying the remarkable progress that has been made, there are still significant gaps in the response, particularly for key and vulnerable populations. With a wave of components being identified for transition, there are already documented concerns about the sustainability of programs post Global Fund withdrawal. This is the case even in countries such as Panama that are already financing the majority of their programs. The Global Fund needs to recognize that its current approach to the region is putting lives at risk and runs counter to the Fund’s mission of a world free of the burden of AIDS, tuberculosis and malaria with better health for all.
Kataisee Richardson is a consultant who works with communities on health and development issues, and a correspondent for Global Fund Observer.