The Office of the Inspector General (OIG) found much to admire in its diagnostic review of a Round 9 HIV grant to the Caribbean Community Secretariat (CARICOM). The OIG said that it had observed many good management and programme practices in the implementation of the grant, and that the grant was a good model of how a regional grant should work in small island states.

A diagnostic review is less detailed than an audit. The objective of the CARICOM diagnostic review was to identify and share good practices, identify key risks to which the grant programme was exposed, and make recommendations for risk mitigation where weaknesses and gaps were found.

The activities of the grant were administered by its seven sub-recipients (SRs). The total grant budget for Phase 1 was $11.2 million of which $9.5 million had been disbursed at the time of the review, which was done in July 2012.

The programme implemented under the grant had two main thrusts: (a) strengthening health systems and supporting the delivery of antiretroviral therapy in six countries of the Organization of Eastern Caribbean States (OECS); and (b) preventing HIV infection among marginalised groups of people and promoting the realisation of their human rights in all 16 countries included in the programme. The programme was managed in coordination with other international donor-funded programmes in the region and was complementary to programmes supported through Global Fund country grants for HIV in Haiti, the Dominican Republic, Jamaica, Guyana, Suriname and Belize.

The OIG said that the programme demonstrated the rationale for multi-country Global Fund support in two ways:

• First, the HIV treatment and health systems strengthening component in the six OECS countries has contributed to establishing a quality system of HIV care and a functional pooled pharmaceutical procurement and supply management system. Due to their small population size, the six countries benefit considerably from the economies of scale of a multi-country approach.
• Second, the policy and social mobilisation initiatives for the protection of the human rights of sexual minorities and of people living with HIV have started to show results in terms of shifting media discourse, reducing violence against sexual minorities, and opening a discussion of issues related to stigma and discrimination at the highest levels of government in the region.

The OIG said that the advances in the area of human rights were facilitated by the fact that the CARICOM Secretariat has access to prime ministers, ministers of health and chief medical officers in the region. The OIG described a two-pronged approach of working both at the policy making and community levels. The OIG said that this had resulted in the adoption of model anti-discrimination legislation by the Legal Affairs Committee of CARICOM and the successful mobilisation of sex workers in the Dominican Republic against a law designed to create “tolerance zones.”

The OIG said that it spotted many examples of good management and programme practices by the SRs and sub-SRs visited during the diagnostic review. The following were among the examples cited by the OIG in its report:

• The consolidated reporting of jointly financed training activities to multiple funders is a good example of the implementation of the Paris Declaration on Aid Effectiveness.
• The one-year curriculum of structured in-service learning at the Caribbean Health Leadership Initiative at the University of West Indies is an innovative approach to building leadership in the health sector.
• The work of the Caribbean Vulnerable Communities Coalition (CVC) and El Centro de Orientacion e Investigacion Integral (COIN) to identify and characterise sub-groups of people that are highly vulnerable to HIV infection, and to develop tailored and innovative programmes to reduce their vulnerability, is exemplary – as is the work with groups that have so far received little attention because their existence was not known or acknowledged (e.g. injecting drug users, adolescent male sex workers and homosexual adolescents).
• The rights-based approach applied by COIN and CVC in their work with adolescents of all sexual orientations is a promising step towards creating awareness and tolerance of sexual diversity in Caribbean society.

In addition, the OIG said, the PR undertook rigorous quarterly financial monitoring of the SRs; this process is well documented; and SRs took action on the findings and recommendations.

At the same time, the OIG identified a number of risk related to programme design. Despite the fact the activities delivered by SRs and sub-SRs were consistently of high quality, they did not fit into an “overall shared program logic,” the OIG said; each SR was a silo. The reasons for this, it said, were two-fold: (a) the geographic, social, linguistic and political realities of the Caribbean; and (b) the difficulty of applying the “Global Fund model” to a regional grant.

The OIG said that this is best illustrated by the performance framework of the grant which assessed performance on the basis of services delivered (i.e. outputs), while the sphere of influence of most grant activities was at the level of changes in the environment in which these services were delivered and changes in the expertise and capacity to deliver them. These changes were not easily captured in the Global Fund performance monitoring instruments and processes, the OIG said.

The OIG also said that linkages among SRs were weak, which made it hard to share good practices.

The OIG said there is a risk that implementing Global Fund programmes will take some NGOs away from their main spheres of work. The programmes for prevention and support among vulnerable populations, which represented by far the largest budgetary component of the grant, were implemented by two regional networks: COIN and the Caribbean Regional Network of People Living with HIV/AIDS (CRN+). However, the OIG said, the mandate of a regional organisation is not typically to reach people with prevention and care services.

The report on the diagnostic review in CARICOM is available on the Global Fund website here.