Open letter to the Global Fund Secretariat
June 27, 2002
Open letter to the Global Fund Secretariat
AIDS activists have been closely monitoring the development of the second Guidelines for Proposals document for the Global Fund to fight AIDS, Tuberculosis, and Malaria (GF). We are extremely concerned by the failure of the current draft Guidelines for Proposals to resolve several of the most glaring errors in the first call for proposals, which was issued early in 2001.
At the end of the first round, only seven funded proposals included antiretroviral treatment components. Lack of clarity in the original Guidelines for Proposals likely played a part in assuring that only a handful of applications would request and be granted money for HIV treatment programs. Unless the GF does its part to help expand the number of proposals that will include requests for money for HIV treatment and that are eligible for such funding, the GF will fail in its stated goal of mitigating the impact of HIV.
As a first step, we call on the Board and the Secretariat to incorporate the following revisions to the final Guidelines for Proposals document in order to increase the likelihood that the GF will make rapid progress in awarding grants to fundable proposals that include substantial antiretroviral treatment components.
+ The GF—in its "Overview" (p. 2) and throughout the Guidelines for Proposals—must articulate the GF's commitment to funding historically neglected responses, especially HIV treatment.
The GF must be unambiguous from the start of this round of application requests—HIV treatment is not just a fundable intervention, it is a required part of a comprehensive application. Interventions focused around treatment access have been typically passed over by funding programs; the GF must not renege on its commitment to fund responses that have been ignored up to now:
insert, p. 2: "8. As an additional and complementary mechanism, the Global Fund will prioritise filling the significant programmatic gaps evident in other local, bilateral, and international programmes, such as current negligible levels of available funding for HIV treatment programs."
The first round of applications was marred by bilateral pressure exerted by donor countries on applicants to scale down proposals, especially proposals that included requests for money for antiretroviral treatment. Country coordinating mechanisms need clarity and leadership from the GF that corrects the damage done by such inappropriate pressure.
+ A commitment to treatment as a necessary and requisite part of any "balanced approach" must be evident throughout the Guidelines for Proposals.
The draft Guidelines for Proposals lack explicit language that directs countries to incorporate treatment programs into their proposals. This can be remedied by inserting clarifying language in several areas of the Guidelines, such as:
Balance of Interventions p. 9: insert "As the Global Fund is a new, non-duplicative, additional funding mechanism filling programmatic gaps, a balance of interventions will in this case favor attention to historically neglected interventions, especially HIV treatment programs. Therefore, a CCP will be considered imbalanced if HIV treatment components—including antiretrovirals—are excluded"
and: Characteristics of a successful proposal, Annex I, insert: "Attention to neglected or unaddressed programmatic components, especially HIV treatment, including antiretrovirals."
+ Cost-effective interventions—ruling out antiretroviral treatment? (cf. p. 10)
Access to treatment, including antiretroviral treatment, is a fundamental human right. There is currently no consensus regarding the comparative cost-effectiveness of antiretroviral treatment when judged against other interventions; it is our belief that antiretroviral treatment remains a key and necessary ingredient of any comprehensive approach to combating HIV/AIDS.
The GF has indicated it is committed to funding antiretroviral treatment. However the draft language in the Guidelines for Proposals regarding cost-effectiveness is deliberately ambiguous and will be interpreted by many prospective applicants to mean that antiretroviral treatment programs are ineligible for money from the GF.
This ambiguity must be corrected in the final Guidelines for Proposals by deleting the phrase "cost-effective" (p. 10) or clarifying that interventions such as antiretroviral treatment will be funded by the GF, and are expected to become increasingly cost-effective over time, as economies of scale are achieved for purchasing medicines, as existing treatment projects are scaled-up, and as spillover benefits to prevention are care are derived from extending the lives of HIV positive people through antiretroviral treatment.
+ The Guidelines must state that the GF will pay for generic medicines. In preparing the first round of applications, CCMs reported pressure from donor countries and other advisors to exclude generic HIV medicines from their proposals. The Guidelines for Proposals can help correct the misconception that the GF will not pay for generic medicines, for example:
"V. Budget Requirements; 56. Drugs: ARVs, drugs for opportunistic infections, TB drugs, anti-malaria drugs, etc. Brand-name drugs or generic versions are acceptable, according to the applicant's situation; lowest-cost commodities must be procured wherever possible."
Further, the GF should make clear to CCMs that it will not dictate whether quality drugs from generic or proprietary sources should be procured with GF monies, but the GF expects that applicants will, on principle, seek out the lowest cost source of supply in order to maximize limited resources. The GF should state that it will evaluate favorably efforts by CCMs to drive down the price of quality medicines, through efforts such as bulk drug procurement and issuing (where relevant) compulsory licenses for production of medicines by manufacturers other than the patent holder.
for example: "VIII. Procurement and Supply Management; insert 85. The Global Fund will support proposals that maximize access to health commodities by securing their purchase and distribution at the lowest possible cost, through use of provisions such as bulk commodities purchasing and, where relevant, compulsory licensing."
+ Technical assistance must be available for CCMs completing proposals. Many prospective applicants lack technical expertise and experience in drafting feasible proposals that include substantial HIV treatment components. If the GF truly wants to increase the number of fundable and comprehensive proposals, it must acknowledge the challenges faced by countries in preparing applications that incorporate treatment programs. The GF should identify sources of free independent technical assistance, and direct applicants to such assistance.
The GF sets rigorous standards for accountability, monitoring and evaluation, and sustainability of interventions—and rightly so. High expectations for applicants should out of fairness and balance be coupled with information about technical guidance, that CCMs can avail themselves of, as needed.
The XIVth International AIDS Conference in Barcelona begins July 7. At this conference, the progress, decisions, and activities of the GF will be scrutinized by media, activists, consumers, clinicians, and researchers from around the world. We call on the GF to revise the draft Guidelines for Proposals immediately to incorporate the above concerns. The GF was developed as an emergency mechanism to aid response to the global AIDS disaster. As the Secretariat well knows, we have no time to waste.
Signed,
Health GAP
Asia Russell
+1 267 475-2645
asia@critpath.org
www.healthgap.org
Act Up-Paris
Gaelle Krikorian
+33 609 17 7055
galk@noos.fr
www.actupp.org
Critical Path AIDS Project
Julie Davids
+1 267 475-2680
jdavids@fight.org
www.critpath.org
cc: Board Members, the Global Fund to fight AIDS, Tuberculosis, and Malaria TRP, the Global Fund to fight AIDS, Tuberculosis, and Malaria