Transition and sustainability are critical issues in Latin America and the Caribbean (LAC), and Global Fund-supported mechanisms in the region need to be better harmonized, concludes a new report, ‘Optimizing the Global Fund Resources’. The report was commissioned in March 2019, jointly by the LAC delegation to the Global Fund Board and the Horizontal Technical Cooperation Group (HTCG), a LAC initiative created in 1995 to improve responses to HIV and other sexually transmitted infections.
The report presents the results of a survey and interviews carried out in 2019 on the experiences and opinions of stakeholders engaged in the response to the three diseases. It focuses on Global Fund-supported processes and mechanisms in the Latin America and Caribbean (LAC) region.
The survey at the heart of the report represents the views of 69 respondents from 17 countries, including representatives from national NGOs, regional networks, the government, CCM members and international agencies and NGOs. Ten key stakeholders described as having “extensive work experience and recognition in the region” were also asked to provide their insights through in-depth interviews. The report was finalized in September 2019, however only the executive summary was made public and widely disseminated in November 2019.
“The LAC Delegation wants to trigger a discussion on how we could use more strategically the limited resources [available] in a non-priority region,” says Javier Hourcade Bellocq, member of the LAC Delegation. He hopes that the findings discussed in the report will spark a meaningful conversation on how to harmonize and optimize the many regional coordination structures currently operating in the LAC region.
LAC has received country allocations totaling $373 million for the 2020-2022 allocation period, a 19.5% increase compared to the 2017-2019 allocation of $312 million. As of May 2019, there were 42 active Global Fund grants in Latin America and the Caribbean, implemented in 18 countries and through six multi-country projects. In addition, 15 countries had conducted transition readiness assessments and a total of 12 grants were under development in 6 countries and for 3 multi-country initiatives (HIV-LA, HIV-CAR, TB-LAC).
The specific objectives of this survey were to:
- Assess the transition processes taking place in the LAC region, taking into consideration the different dimensions established by the Global Fund itself in order to ensure they are inclusive, including both programmatic and financial considerations.
- Assess the sustainability of the response at country and regional level, taking into consideration the provision of prevention, diagnosis, care and treatment services.
- Assess the functioning and implementation of mechanisms supported by the Global Fund in the LAC region.
The survey’s key findings focused on three major themes: ensuring a smooth transition from Global Fund to government funding of programs and ensuring the sustainability of the response to the three diseases; reviewing the effectiveness of the two Global Fund-related regional coordination mechanisms; and assessing the effectiveness of the Global Fund Secretariat’s communication and coordination efforts to provide recommendations for improvement.
Sustainability and transition
According to the survey, 76.8% of respondents, had participated in activities related to sustainability and transition at the national and / or regional level, while 23.2% say they have not participated in these activities – suggesting that this continues to be an area of concern. At the national level, these activities were mostly related to sustainability and transition planning for the funding request or meetings and workshops.
Only 27.5% of respondents consider the national response to the three diseases (in their country) to be technically and financially sustainable once the Global Fund concludes its current grants. Thirty-four percent (34.8%) felt the response would not be sustainable and the remainder (37.7%) were unsure, saying it may be sustainable. The views of those working in government diverged widely from the views of civil society. In fact, 94.5% of government officers or national program managers consider the response to be sustainable in their countries, compared to just 7.4% of NGOs and national/ regional networks members.
Many respondents felt concerned about the sustainability of the community response, especially for HIV prevention. Although countries have been tasked with developing social contracting mechanisms, respondents believe that this could take time and that civil society need to proactively define strategies to ensure their sustainability in the absence of funding from international donors.
Those who doubted the response would be sustainable cited numerous reasons; the low profile of HIV (in particular) in government agendas; the wave of “conservative governments” that are hostile to key populations; shrinking support for civil society organizations; economic stagnation and decline that compromises people’s quality of life ; an exclusionary approach that ignores cultural diversity and underserved populations such as migrants, rural populations, people in prisons and indigenous people; and the absence of a comprehensive, coordinated multisectoral response to the three diseases.
According to the report, an interviewee noted that "one of the biggest problems in the region is that the response is still thinking only about governments and the health sector. It has not been able to break the ‘straitjacket’ of the field of health. We cannot forget that given the people with whom we work, we are talking not only about a public health issue, we are talking about a human rights issue. The focus on medication and the condom is not enough to ensure sustainability or even think countries will meet the goals that were agreed to".
The report’s authors also assessed the respondents’ awareness and perceptions of two regional mechanisms: The Community, Rights and Gender (CRG) LAC platform and the Regional Advisory Committee for regional grants of the Global Fund in LAC (CARLAC).
- The LAC platform enjoys a high level of recognition among respondents (78.3%) almost exclusively by those who have a role vis-a-vis the Global Fund grants (98.5%). However, (75.3%) of those belonging to NGOs/national level networks did not know about the existence of the platform.
- According to most respondents, the LAC platform was falling short of meeting its objectives. It scored “low” or “moderate” on the four objectives of: a) informing community groups about the Global Fund, b) improving their access to technical assistance, c) promoting strategic capacity building and d) coordinating key actors in the region. Very few respondents could identify specific examples/experiences related to each of the established objectives.
- There is a perception among interviewees that the LAC platform is “a team of consultants”.
- 72.5% of respondents are aware of CAR-LAC. However, the data shows that having a role that is related to Global Fund grants correlated highly with this awareness. Of respondents who did, 90.5% knew about the CAR-LAC, while 89.5% of those were not involved in the Global Fund were not aware.
- When asked to describe the role of the CAR-LAC, there was some confusion regarding the scope of their role. The most common response was that the role concerned tracking and monitoring, followed by strategic support to regional grants and technical advice.
- The respondents’ average assessment of the achievement of the CAR-LAC’s five objectives is low. The objectives are a) implement a strategic monitoring system, b) provide recommendations to strengthen regional grants c) provide harmonization, alignment and complementarity d) implement a communication strategy e) provide recommendations to the Global Fund on strategic directions of future grants.
- Surveyed individuals also felt the CAR-LAC duplicated the work of other existing structures, lacked public and transparent mechanisms for selecting its members, and needed to revise the terms of reference and roles of its members. There is a mismatch between the competence and capabilities of the members of CAR-LAC and roles they are required to perform, since members do not respond adequately to the expected performance objectives.
The Global Fund
73.9% of respondents know the fund portfolio manager for their country or regional initiative. And the majority of respondents (67.6%) said they had participated in meetings with the fund portfolio manager for their country or regional initiative, either individually or in groups.
In the event of a problem, 42.9% said they would communicate with the fund portfolio manager, followed by the Office of the Inspector General (OIG; 11.1%), the NGO/ Communities Delegations (10.1%), and the LAC Delegation (6.6%). The remainder would contact the CCM, regional network or a UN agency.
Respondents identified a number of recommendations for the Global Fund:
Facilitate the participation of civil society, including raising the profile of civil society in the response, involving people living with HIV in funding requests and engage them in regular dialogue;
- Look beyond GDP and revise eligibility criteria to account for inequalities that exist within Latin American and Caribbean;
- Expand their knowledge of the national reality, region and actors;
- Further mainstream human rights and universal health coverage;
- Avoid duplication of structures;
- Deepen coordination and exchange between countries and projects;
- Promote horizontal relationships and teamwork within the Secretariat;
- Improve communication through increased visits and troubleshooting;
- Streamline processes to reduce response times and administrative burden.
The executive summary has been circulated within the Global Fund Board and among relevant regional stakeholders. The LAC delegation met with the LAC team at the Secretariat, who received a copy of the full report, to discuss the findings. The LAC team expressed their gratitude for the report and agreed to follow up on some of the recommendations and make improvements. “The full exercise was for us, as the LAC delegation, to listen in a more structured way and reassure our constituencies that we will continue working in and out of the region to improve those [issues raised] and other things, without micromanaging the Global Fund”, says Hourcade Bellocq.
The LAC Delegation will also be reviewing these recommendations as it develops its own Board delegation workplan for submission to the Secretariat.
Reactions to the Report
The Global Fund Secretariat did not participate in the design or analysis of the survey so they were unable to comment in detail on the analysis presented. However, Paul Bonilla, Sustainability and Transition Specialist for Latin America and the Caribbean says: “Sustainability is a serious concern. We will never end epidemics without effective transition to domestic financing in many countries. The Global Fund continues to engage with civil society, governments and partners to support country ownership in shaping and improving the sustainability of national responses.”
He points to transition readiness assessments that have now taken place in 16 of 18 eligible countries in the region, and grants that are funding priority actions to reduce transition-related bottlenecks. “There are real challenges in some contexts and we are committed to addressing them as much as possible. It is a collective responsibility, and we are committed to working with all partners”, says Mr. Bonilla.
Anuar Ismael Luna Cadena, Technical Coordinator for the LAC Platform, counters the findings of the report. He said that in 2019, the LAC Platform webpage had a total of 29,837 visits, and a total of 15,314 users. The users of the webpage included 27 countries in Latin America, Luna said. The LAC Platform also has a bimonthly newsletter, a social media following on Facebook and Twitter, a Mailchimp alert system, a document repository and a webinar program. A major component of their work is supporting organizations and networks to develop requests to the CRG Strategic Initiative’s short-term technical assistance program. In July, they hosted a learning and sharing forum for communities engaged in Global Fund processes at the national and regional level with 73 registered participants.
Despite these achievements, the LAC Platform believes that a coordination strategy is needed in the region, among other communication initiatives, in order to maximize the impact and efficacy of the information they all share.
“The LAC Platform is aware of the need of create alliances with other key stakeholders in the region, such as networks, donors, multi-lateral agencies, regional and country level initiatives, for these reasons we are building a robust collaborative effort with a range of actors”, says Mr. Luna.
- 'Optimizing Global Fund Resources': Executive Summary (in Spanish); the full report is not available publicly but interested parties can request a copy of the Spanish version from the LAC Delegation to the Global Fund Board