Editor's note: The biggest challenge facing the Global Fund is to ensure that grant disbursements actually lead to people receiving the promised treatment and prevention services. Often, despite good will and hard work on the part of many, entrenched bureaucracy or political unrest can provide major barriers. Nepal, which is close to civil war and has had three changes of government since its $4 million Round 2 HIV grant was approved in January 2003, is one such country. Four days ago, Rajiv Kafle, an HIV-positive activist in Nepal, wrote the following open letter to the Global Fund leadership at the end of a frustrating day.
Thursday 14 October 2004
Dear Dr. Feachem and Global Fund Board members,
I woke up at 5 today. I was invited to Nepal's UN day celebration. Everyone was invited - from the Prime Minister to a group of street kids - and they all looked happy. But that certainly wasn't true of the people I had to meet.
First was the head of UNAIDS in Nepal. He was quite frustrated over the government's slowness in coming up with an agreement in which the UN will help implement Nepal's Round 2 Global Fund HIV grant. "This is not working," he said. He looked like the commander of an army that is losing a battle. He has spent more time on this than anyone else from the UN, and he knows what works and what doesn't. However, the last thing I wanted to hear early in the morning was that it is not working. Many of us have devoted lots of energy for more than a year now to make this work.
Then we were joined by the Chair of the UN theme group. She too was not very hopeful. The Ministry of Health, as the Principal Recipient of the grant, has to agree to an arrangement in which the UN system will serve as the grant's Management Support Agency. And it has to do so soon, or - so the Fund tells us - a new PR will have to be found, which will turn the clock back to zero.
The Fund's board approved the grant nearly two years ago, in January 2003. Coincidentally, I had attended that board meeting, as a member of the Developing Countries NGO delegation. A journalist had asked if I was happy that my country was receiving the grant. I had answered "No," because I thought that the money probably would not reach the right people. However, over the course of the following year we did a lot of advocacy to get the money reallocated so that it will go to the right people. As a result of that, the government even started the ARV program early, anticipating that they would receive the Global Fund money to continue it and build the number under treatment up to 2,500. But now the chances don't look so good. This is a challenge for the Fund, too. If it changes PR or cancels the grant, many who have started ARVs will die.
I left the UN building wondering yet again what I can do to help solve this crisis. Next, I had to visit a friend in the hospital. He had stayed with us in our center for a long time. Recently his health started to deteriorate. His TB medicines were not working. I sat next to him. I simply have no words to explain how he looked. He has gone blind and he cannot speak much. He asked me softly, "Am I dying?" I immediately answered "NO, you will get well soon, and together we will celebrate the Dashain festival that starts next week." I am a liar. He is dying. The doctors had told us they were waiting until he gained some weight and adjusted to the TB meds so they could then put him on ARVs. Well, now he may not need the ARVs. I can't take any more death, my little group already had five this year.
Just next to the hospital is the NationalCenter for AIDS and STD Control (NCASC), which comes under the Ministry of Health. I went to meet the director there. I told him that we are organizing a protest in his office next week for not putting more people on ARVs as he had promised. The government started with 25 people in April and had promised to scale it up to 125 by September. I showed him the poster we had printed for the protest. It read "ACTION ALERT!!"
His face had a similar expression to that of the UNAIDS main I had talked with this morning. He said "I worked very hard when I had to prepare for my marriage; I worked harder still when I had to arrange my son's marriage; and now in the past one year I have worked the hardest of all to make this Global Fund project work. Please help me for the last time." He added, "I will retire in four months but I am committed to make this work."
He took out a document and gave it to me. This was the contract he had drafted, at the request of the Global Fund, between the government and the UN system. The UN has already done nearly all the required work covered by the contract - procurement plan, monitoring and evaluation plan, and more. But this need for a formal contract before money can flow is a real problem. The Ministry insists that the contract be approved by the cabinet, the top council of government. In these troubled times, cabinet meetings mostly focus on security issues. He explained to me that there may not be enough time to meet the Fund's deadline. And in a rather hopeless tone he asked me "How is the Global Fund different from any other mechanism?" I said nothing. But I left him thinking that I will surely write a letter to Richard Feachem and ask him the same question.
[Rajiv Kafle (firstname.lastname@example.org) is Coordinator of Nav Kiran Plus, an HIV counseling and rehabilitation NGO in Nepal that is caring for 60 people. A former board member of GNP+, the Global Network of People Living with HIV/AIDS, he has led sit-ins with other people living with HIV/AIDS in front of the UN building in the capital Kathmandu, urging officials to prioritize care and support programs.]
[Editor's follow-up note: Taufiqur Rahman, Global Fund Portfolio Manager for Nepal, has responded privately to Rajiv, and has sent the following comment to GFO: "We are acutely aware of the critical need for urgent, decisive action to move the Nepal grants forward and are exploring all options to make this happen. We are taking concrete steps in consultation with donors and partners to make sure funds flow immediately from the Principal Recipient, the Ministry of Health, to sub-recipients. Our actions will ensure the PR disburses funds for ARV procurement within the next four weeks and we will provide an update on the situation to GFO in November."]