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Global Fund Observer


Issue 238: 04 March 2014

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1. NEWS: The Global Fund releases eligibility list for 2014

The Global Fund has released the list of countries eligible to apply for a share of the $12 billion raised in the fourth replenishment cycle to fund activities in each of the four components: HIV, TB, malaria and health systems strengthening.

2. NEWS: Global Fund expresses “deep concern” about new anti-gay law in Uganda

The Global Fund expresses deep concern about the public health implications of a new anti-gay law in Uganda

3. NEWS: Prison feeding programs for HIV and TB inmates more than a matter of supplying food, Global Fund sub-recipients find

The Global Fund is working in several countries in Africa, including Côte d’Ivoire, to support feeding programs in prisons for people infected with HIV and TB. But if the idea is simple, in practice it is substantially more complicated.

4. NEWS: Ukraine activists seek stability in HIV/TB funding in face of political turmoil

Political instability in Ukraine could compromise some of the progress towards an envisioned handover of Global Fund-supported activities to the public sector by 2017.

5. COMMENTARY: The Global Fund and the fears of transparency

In 2002, the new Global Fund was a world leader in aid transparency. It had committed to publish a volume and level of technical details on its grants that was unprecedented in international development.

See section near the end of this newsletter listing additional articles available on GFO Live.

1. NEWS: The Global Fund releases eligibility list for 2014

Eligible countries will develop their proposals in line with requirements under the new funding model

The list of countries eligible to apply for Global Fund support for up to four components -- HIV, TB, malaria and health system strengthening --  was released in February, timed to coincide with the imminent roll-out of the new funding model (NFM) allocating greater resources to those countries with high disease burdens and modest financial resources.

Each country may develop and submit concept notes for any or all of the components they are eligible for.  

A number of countries with high incidence of co-morbidity of HIV and TB will be required to submit an integrated concept note.  The World Health Organization has identified 41 countries as priorities for integration of HIV/TB activities; two of them -- China and Brazil -- are not, however, eligible for Global Fund support due to their income classification. A third ineligible country, Russia, is only able to apply for Global Fund funding under an exceptional rule that allows HIV proposals to be developed by non-governmental organizations.

Countries included in the 2014 eligibility list will be allocated a proportional share of the more than $12 billion raised during the fourth replenishment, launched in December 2013, for the period 2014-2016, based on disease burden and ability to pay. 

The Global Fund Secretariat has estimated that countries will be preparing and submitting 321 proposals for financial support for activities in each of the four components during the cycle.

Eligibility was calculated on a methodology that assesses disease burden and gross national income per capita. Classification into income bands is based on a methodology created by the World Bank and used by organizations including the Global Fund. 

An announcement about the amount of money available to each of the eligible countries based on the new allocations formula under the NFM is expected following the Global Fund Board meetings opening on 5 March in Jakarta. Countries will first be assigned to a band and then provided with a funding allocation envelope with a suggested disease split reflecting burden.

The list includes 125 countries eligible to apply for funding for at least one component, with some caveats. Countries including Belarus, Romania and Russia are eligible for HIV funding only under the NGO rule, which requires proposals to be submitted not by a country's coordination mechanism (CCM) but by a non-governmental organization that has identified itself as an independent implementing entity (see articles here about the NGO rule).

Other countries such as Iraq and Fiji are only eligible for TB funding under the transitional provisions of the new eligibility policy. 

An analysis of the list by Aidspan reveals only minor changes in eligibility since 2013. The changes are:

  • Belarus, Bulgaria and Kazakhstan are newly eligible for HSS
  • Chile, Latvia, Lithuania and Uruguay are no longer eligible for Fund support
  • Belize's eligibility is restricted to HIV and TB
  • Peru is no longer be eligible for HSS funding but remains eligible for HIV and TB
  • Seychelles has been included among eligible countries, but only for HIV
  • Tonga is no longer be eligible for HSS funding

Specific components in some individual countries included in the eligibility list are also shown as being subject to 'pre-defined maximums'. Aidspan understands from consultations with the Secretariat that allocations subject to these 'pre-defined maximums' will be applied as a fixed amount based on population size, to a small number of upper middle income countries with high burdens of one or more disease components and small island economies. 

Countries affected by this pre-defined maximum include: Algeria, Azerbaijan, Belarus, Belize, Botswana, Bulgaria, Colombia, Costa Rica, Cuba, Dominica, Dominican Republic, Ecuador, Grenada, Iran, Jamaica, Malaysia, the Maldives, Mauritius, Panama, Peru, Romania, Russia, the Seychelles, St Lucia, St Vincent and Grenadines, Suriname, Tonga, Tunisia, Turkmenistan and Tuvalu.

The full eligibility list is available here.

*Read the article in French. Lire l'article en français.

[This article was first posted on GFO Live on 26 February 2014.]

To comment on this article, click here.



2. NEWS: Global Fund expresses “deep concern” about new anti-gay law in Uganda

Implications for public health ‘grave’ – increase in transmission likely

The Global Fund has expressed “deep concern” about a law signed by Ugandan President Yoweri Museveni that imposes jail terms of up to seven years for those who ‘aid or abet’ homosexual relations, which could implicate health workers providing services and counseling to people living with HIV.

In a statement released on 24 February the Fund decried the new legislation for its “significantly tough[er] punishments against gay people” and “grave implications for public health”.

UNAIDS has estimated the HIV burden in Uganda at 1.5 million people, from a population of roughly 35 million. At 13%, the prevalence of HIV among men who have sex with men is roughly twice the national prevalence rate of 7.3%. This is in line with global estimates that men who have sex with men are around 13 times more likely to become infected with HIV than the general population.

Fear of legal repercussions such as incarceration, or illegal consequences such as physical abuse, will likely prevent many men from seeking care and services in Uganda. These fears are mirrored by research that shows that when persecuted populations face discrimination they are less likely to seek testing, prevention and treatment, placing them at even greater risk of HIV infectionand HIV-related death, and making it more likely that they will transmit HIV.

“The retrogressive legislation just signed into law in Uganda is the tip of the iceberg of homophobic attitudes in a number of African countries. It reminds me of the bizarre denialism we saw in South Africa in 2000,” said Alan Whiteside, CIGI chair in Global Health Policy at the Balsillie School of International Affairs and Wilfrid Laurier University.

“It will cost lives and put back the fight against HIV. This blind prejudice is incomprehensible; bad leadership; terrible public health; and blinding intolerance. The enlightened African leadership and donors need to take a stand.”

In its statement, the Fund urged Uganda, among other governments, to “protect the human rights of lesbian, gay, bisexual and transgender people. We support repealing criminal laws against adult consensual same sex sexual conduct, implementing laws to protect against violence and discrimination, promoting campaigns that address homophobia and transphobia, and ensuring that adequate health services are provided to all.”

Uganda is the second African recipient of Global Fund grants that support HIV activities to sign into law anti-gay legislation in recent weeks, joining Nigeria among the ranks of the more than 30 countries on the continent that now have imposed harsh and discriminatory criminal penalties for homosexual behavior.

Ugandan Health Minister Dr Ruhakana Rugunda told the BBC on 26 February that all Ugandans will remain at “complete liberty to get full treatment and to give full disclosure to their doctors and nurses” even under the new law, insisting that sexual orientation would not be a factor in access to services.

But Ugandan activists say otherwise. The privately funded Ice Breakers Clinic, which worked exclusively with a gay clientele in the capital Kampala has suspended operations for fear of legal repercussions or attacks from the public couched as adherence to the law.

Shock that the law was passed after several previous iterations were vetoed by Museveni has also reverberated around the Global Fund itself. A Ugandan member of the developing country NGO delegation to the Board saw his membership terminated on 26 February following the release of emails exchanged with other members of the delegation that used homophobic slurs.

Dr. Patrobas Mufubenga, a malaria expert with the Malaria and Childhood Illness NGO Network (MACIS), has served on the delegation since May 2013. In a statement, the delegation said that it was not until recently that other members “became aware that his views on homosexuality and HIV and AIDS are incongruent with the [d]elegation’s views and the Global Fund’s stance on human rights”.                               

In taking its decision to suspend Mufubenga immediately from the delegation, the leadership said it “reject[ed] and denounc[ed] his sentiments without reservation” and that an application review and interview process would be implemented, going forward, to ensure that a similar situation does not arise again.

*Read the article in French. Lire l'article en français.  

[This article was first posted on GFO Live on 28 February 2014.]

To comment on this article, click here.



3. NEWS: Prison feeding programs for HIV and TB inmates more than a matter of supplying food, Global Fund sub-recipients find

For most inmates in Cote d’Ivoire, the arrival of a friend or loved one with a bowl of rice or attiéké, the local staple of fermented cassava pulp, is a highlight of a long and exhausting day of doing nothing but self-preservation.

But for those inmates infected with HIV or TB, that nourishing bowl can make the difference between life and death can, helping to stave off the dizziness, shakes and stomach cramps that are side effects from taking the medicinal cocktail of anti-retrovirals or first-line TB drugs. And on the days they don’t come, many inmates – like one at the Abidjan correctional facility, Maca – just don’t eat.

“I am too afraid of catching something” from the rations served by the prison, he told Aidspan on condition of anonymity during a recent visit, standing in the health ward waiting to receive his daily dose of anti-retroviral therapy. “I have seen cockroaches in the rice and sauce they serve us. And someone in my ward died from beriberi.” 

The daily food budget per inmate in the Ivorian prison system in 2013 works out to roughly $0.65: enough for some cassava, or rice and sauce, but not nearly enough for a piece of fish, or chicken or even a handful of beans. “We just don’t have the money to spend more to improve the food rations,” lamented Babacar Ouatta, the director of the prison administration.

How to provide proper nutrition to all inmates on tight budgets remains a perennial challenge for prison administrators across the country, a challenge compounded by the nutritional needs of HIV positive or active TB prisoners. The meagre, poor quality rations served to inmates pose a particular threat to treatment success for HIV or TB. Even when drug stocks are available, many infected prisoners decline to take their medication for fear of the impact on their bodies of taking them on an empty stomach.

Malnutrition among people infected with HIV or TB can lead to secondary immunodeficiency, which can increase the risk of infection. Malnutrition can alter the metabolism of TB patients and keep them from properly absorbing nutrients and proteins, causing wasting, delaying recovery and increasing the risk of complications leading to death.

Although there are no current national statistics for the number of infected inmates incarcerated in any one of the 33 Ivorian national penitentiaries, a 2010 survey conducted jointly by the Justice and Health ministries suggested HIV prevalence a year earlier was 10%.

At Maca, the country’s largest penal institution, at least 100 of the 4,800 inmates are HIV positive, according to Rodrigue Abro, who runs the prison’s ARV treatment program, although he thinks the figure is likely much higher. Just 29 inmates were on daily ARVs in February, he said.

Côte d’Ivoire joins a handful of other countries in sub-Saharan Africa where Global Fund money supports feeding programs in prisons, helping to avert the malnutrition problems that can produce complications that lead to death among TB and HIV infected patients. In Rwanda and Namibia, the Fund supports nutrition support for prisoners with multi-drug resistant TB, while 150 prisoners in Madagascar are also enrolled in a Global Fund-supported feeding program.

Under a $17,200-distribution program carried out by a inmates' rights and care group called ESTHER, a sub-recipient of a grant administered by a national program providing care to people living with HIV, 22 prisons around Côte d’Ivoire will be furnished with nutrition kits. The kits are destined for HIV-positive inmates enrolled in an ARV treatment program and contain rice, palm oil and fortified flour. The distribution, to be launched in conjunction with the World Food Program from March 2014, will run for three years, with each $57-kit containing enough food to last an HIV-positive inmate six months.  

Another challenge : where those chosen inmates will eat their fortified meals. Stigma and discrimination can carry rough penalties in prison, one inmate said – and so can being singled out for special treatment.

When it was suggested that he just plan to eat in the infirmary, he demurred. “So I should be going to take my meals in the infirmary every day? No. People will ask too many questions.”

*Read the article in French. Lire l'article original en français.

[This article was first posted on GFO Live on 28 February 2014.]

To comment on this article, click here.



4. NEWS: Ukraine activists seek stability in HIV/TB funding in face of political turmoil

Groups ask Global Fund to accelerate funding commitments to maintain existing programming

Ukraine's HIV community including principal recipients of Global Fund grants have formally requested an expediting of the disbursement of Phase 2 funds under Round 10 in order to counteract the potential impact of the current political turmoil roiling the country.

Ukraine and the Global Fund have successfully navigated turmoil before, but the current crisis that has left dozens dead and toppled the former president has thrown contingency planning into question and evoked fears of an epidemiological consequence for both HIV and TB incidence.

In a letter sent in late February, four organizations -- the International HIV/AIDS Alliance, the Center for Socially Dangerous Disease Control under the Ministry of Health, The All-Ukrainian Network of People Living with HIV and the national HIV/AIDS service -- urged the Fund to swiftly disburse funds envisioned for Phase 2 of the grant.

“We know that the Board is meeting in the next few days and we are calling on you to take in to account the latest information from Ukraine instead of allowing your decision-making to be based on false or outdated assumptions,” according to the letter, a copy of which was seen by Aidspan.

Global Fund-supported programs have, since December 2013, been funded on a quarterly basis, which the letter's signatories say has created a feeling of insecurity and instability among sub-recipients. In the letter they say that "this contract will serve as a guarantee for the stability of HIV and TB response in the country.”

The International HIV/AIDS Alliance -- Ukraine's largest NGO -- has served as PR on HIV grants under the Global Fund since 2003, carrying out activities including HIV prevention for key populations, providing harm reduction services, TB diagnostic services and providing treatment for MDR-TB patients.

The Alliance is also spearheading the transition to government ownership of all harm reduction, behavior change and service delivery programs in line with a national strategy (National Strategic HIV Plan for 2014-2018). The plan would see government begin to gradually assume financial responsibility for ART distribution in 2015, and prevention activities in 2017.

For the activists, however, the challenge is that although the former government notionally approved the plan, it is still awaiting formal approval, which could be indefinitely delayed due to the continued challenges in Ukraine. According to Andrei Klepikov of the Alliance, this could have serious financial consequences for the future of HIV programming in the country.

“The financial crisis and the state budget deficit could put the budgetary component of the national plan at risk," he said, noting that already, the devaluation of the Ukrainian currency will make purchasing commodities more expensive.

Infection rates have risen steadily in the last 15 years, with HIV prevalence at 0,66% and the number of new TB cases reported in 2012 at 35 422 . Co-infection of the two diseases is estimated at around 33% of people living with HIV.

Escalating concerns about the future of the long-term relationship between the Global Fund, its in-country partners and the Ukrainian state were illustrated by a bill that made its way through parliament that required all NGOs receiving foreign assistant to register as international agents: a bill that echoed a similar law in place in Russia since 2013. The effects of the law next-door have been chilling, forcing many NGOs working in social justice, transparency and public health to close their doors.

While the bill ultimately did not become law in Ukraine, political pressure on NGOs, including the Alliance has decidedly increased, according to Klepikov. “Global Fund-supported activities in Ukraine were really on the radar screen of the security services, so despite the formal cancellation of the bill, there was real pressure on" he told Aidspan.

Another hurdle that the political turmoil has placed in the way of Fund partners in Ukraine was anti-dumping restrictions that have prevented the release from customs of materials for a harm reduction program targeting injected drug users. Procured in September 2013, some seven million syringes worth an estimated $275,000 have remained in custody, awaiting resolution of a dispute over tariffs.

The Alliance would distribute these syringes to drug users as part of a needle-exchange program designed to reduce the risk of transmission of HIV via dirty or shared needles.

“Unfortunately, all our attempts to release the syringes with involvement of the Minister of Health remain unsuccessful until the end of 2013," Klepikov. "At the moment, there is no official body to negotiate with, because the ministry has been restructured and we are waiting for new officials to be appointed."

Also of immense concern to the Alliance are the mounting barriers to access in the southern Crimea region; the regional capital, Sevastopol, is one of 300 cities around the country where harm reduction and ARV therapy activities are being carried out. Klepikov said that since Russian troops have moved in to seize command of the region, there are risks that ART delivery will be compromised, along with harm reduction programs -- which are banned in Russia.

“We have serious concerns with regards to stopping harm reduction programs in the area that is so heavily influenced by Russia, which has banned harm reduction at home," Klepikov said. "We consider that renewing a three-year contract with the Global Fund will help with policy advocacy in that regard as well."

[This article was first posted on GFO Live on 04 March 2014.]

To comment on this article, click here.



5. COMMENTARY: The Global Fund and the fears of transparency

In 2002, the new Global Fund was a world leader in aid transparency. It had committed to publish a volume and level of technical details on its grants that was unprecedented in international development.

It was my privilege to be part of the Fund at that time, and to have my eyes opened to the complexity of delivering on transparency. It taught me that the disclosure of information alone is unlikely to bring about change in development aid (see previous commentary.)

Yet it appears that the Global Fund has lost some ground in maintaining its founding commitment. According to the 2013 Aid Transparency Index, a global measure of donors’ aid transparency, the Fund is now ranked sixth behind other organizations. While sixth is still 'good', it means that the Fund is no longer considered exemplary when it comes to transparency.

This turn of events may be explained by a number of reasons, both human and technical. The Global Fund is just like any other institution: made up of people who bring feelings, like fear, to work. And transparency, a great objective in principle, unleashes some of those fears: the fear of losing the support of donors (if data doesn’t paint a positive picture of one’s results) and of damaging working relationships with partners (if data highlights serious problems in the implementation of programs).

As a result, the natural tendency is to be protective about what filters out to the press, to spin and sometimes to self-censor. I'd like to share a few examples of what I experienced at the Fund and some ideas that may be helpful in adapting to the challenges ahead.

Communicating with the press

In January 2011, the Global Fund’s honeymoon with the press came to an abrupt end. A wire story about the outcome of some of its own investigations on corruption in Africa spread like bushfire, jeopardizing hundreds of millions of dollars in donor contributions, paralyzing disbursements and severely slowing down grant implementation.

This first major crisis was a defining moment for how the Fund manages transparency. Some within the ecology felt bound to defend the Fund as a victim of its own openness, noting that it was the Fund's decision to release the investigation reports that was the foundation of the story. We in the Communications department were also partially responsible for how the story unfolded. Rather than widely sharing the information with journalists, we posted an announcement on the website before the holiday season and considered the job done. It was only two months later, when a journalist claimed that he had uncovered something, that we initiated our response. But by then, we were fighting allegations of a cover-up, rather than running the story.

Communicating on grant performance

The Global Fund depends on partnerships and collaboration among a highly diverse, yet interdependent, group of people. Grant recipients depend on the Fund’s good ratings to keep on supporting their work; donors and the Global Fund depend on good performance by grant recipients to prove high impact from investment. In this context, there are competing pressures for communications and managing sensitivities and professional relationships.

Those competing pressures were likely responsible for the decision to abandon the web-based Early Alert and Response System (EARS) established in 2006 to identify poorly-performing grants and enable quick corrective measures.

As was outlined in the Five-Year Evaluation of the Global Fund (PDF, p. 48), “the application of EARS has generated some mistrust among Global Fund partners who expressed concerns over the ‘stigmatizing effect of the EARS list’”. This conclusion was based on comments made at a regional meeting to the effect that “EARS could be used by NGOs to embarrass PRs (Principal Recipients) by going to the press. Information needs to be shared cautiously”.

Opening up the communication gates

Social media has engendered a great deal of public mistrust in any institutions trumpeting their own success with highly packaged stories that only emphasize the good and downplay the bad; what is more 'successful' seems to be an openness to interactive engagement and a recognition that all does not always go as planned. The Global Fund is known for the high quality of its top-down communications (publications, photos, videos), but it stops short of support for online discussions with and among implementers and other in-country partners.

In 2007, the Global Fund created, a social media website that invited free and open discussions on the implementation of grants and the Fund’s strategic directions. This initiative initially raised doubts and legitimate concerns (summarized here). By opening up the communication gates, some wondered, how would the Fund avoid unleashing hordes of critics waiting to destroy its reputation? The results proved to be overwhelmingly professional and constructive. As of early 2009, MyGlobalFund had been used to hold several thematic discussions that led to a series of strategic recommendations, many of which were adopted by the Board. But it has been offline 'temporarily' since 2010 -- which seems like a missed opportunity.


When millions of lives and billions of dollars are at stake, it makes sense to want to carefully control communications, limiting the message to a top-down approach. But I think that careful control has limited the benefits and value that comes from transparency. Responsible image management and full transparency are not incompatible; it's not a stark choice between control and chaos. The Fund can reclaim its position as a leader in aid transparency while also playing by the new rules, and winning, in global communications.

First, it should encourage journalists to investigate the impact of Global Fund programs. As a steward of life-saving money for millions, the Fund has every reason to want to cautiously manage its external relations. But it cannot micromanage a global army of journalists, bloggers and activists. Instead, the Fund could seek to work more closely with journalists, providing proactive support for investigations into the use of grant funds and their impact and results, enlisting journalists as an early warning system. Moving towards aggressive promotion of transparency will help boost the Fund's credibility, build trust and shift the focus to the countries where progress is being made and concerns are being raised.

The Fund should also work to provide better tools for watchdogs and citizens to demand accountability from grant recipients at the country level. This means a more strategic website that features clearly visualizable data sets and infographics that will help strengthen the arguments for people in recipient countries to demand better accountability.

Finally, the Global Fund should deploy all of those experts and supporters around the world waiting to contribute to its success with their valuable experience, unique perspectives and constructive criticism. The Fund’s website is an impressive repository of information, but it doesn't promote interaction and engagement. A more strategic use of social media that embraces permanent two-way communications with and among grant implementers and in-country experts will help it nurture the contributions of experts with first-hand experience of the fight against the three diseases in funded countries. The Fund is, and will remain, a giant learning experiment, regularly having to adjust to changing conditions. As such, it is one of the global organizations that stand to gain the most from a clever use of social media.

The world wants to be impressed as much by the Fund's results in saving lives as by its capacity to generate trust for the way it manages development aid. The Global Fund and all its data and information belong to the world. Half measures are not an option.

Robert Bourgoing is a strategic communications specialist. The views contained in this commentary are his own.

*Read this commentary in French. Lire ce commentaire en français.

[This article was first posted on GFO Live on 04 March 2014.]

To comment on this article, click here.



The following articles have been posted on GFO Live on the Aidspan website. Click on an article heading to view the article. These articles may or may not be reproduced in GFO Newsletter.

NEWS : Sida et tuberculose en prison : le problème de la nutrition des détenus malades

En Côte d’Ivoire et dans d’autres pays, quelques initiatives soutenues par le Fonds mondial tentent modestement de remplir une condition essentielle du traitement du sida et de la tuberculose en prison : nourrir correctement les détenus malades. Si l’idée peut sembler simple, sa mise en pratique s’avère très compliquée. 

NEWS : Le Fonds mondial exprime sa « profonde inquiétude » à propos de la nouvelle loi homophobe de l'Ouganda

Le Fonds mondial exprime sa « profonde inquiétude » à propos d'une loi promulguée par le président ougandais Yoweri Museveni qui prévoit une peine allant jusqu'à sept ans de prison contre toute personne coupable « de soutenir ou d'encourager » les relations homosexuelles, ce qui pourrait s'appliquer aux travailleurs de la santé qui fournissent des services et des conseils aux personnes vivant avec le VIH

NEWS : Le Fonds mondial publie la liste d'admissibilité pour 2014

La liste des pays admissibles pour demander l'appui du Fonds mondial a été rendue publique en février pour quatre composantes: le VIH, la tuberculose, le paludisme et le renforcement des systèmes de santé. Ceci coïncide avec le déploiement imminent du nouveau modèle de financement (NMF) qui alloue davantage de ressources aux pays les plus touchés par les maladies et disposant des ressources financières les plus modestes.

NEWS : Les immenses défis de l’aide du Fonds mondial au Soudan du Sud

La guerre, l’insécurité et l’extrême dénuement du plus jeune pays du monde pourraient servir de cas d’école afin que le Fonds mondial revoie sa manière de gérer son aide aux Etats fragiles.


This is issue 238 of the GLOBAL FUND OBSERVER (GFO) Newsletter.

We welcome suggestions for topics we could cover in GFO. If you have a suggestion, please send it to the Editor of GFO (see contact information below).

Author: Article 1 and 2 : Lauren Gelfand, Article 3 : Aurelie Fontaine, Article 4 : Tinatin Zardiashvili, Article 5 : Robert Bourgoing

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