12 Feb 2020
Allocation letter reflects country’s challenging context and atypical implementation arrangements

For the first time, the Global Fund to Fight AIDS, Tuberculosis and Malaria has allocated to Venezuela funds to support a malaria grant, for the 2020-2022 funding cycle. The amount allocated is $19.8 million for a three-year malaria grant to support “evidence-based interventions for vulnerable populations primarily to fill gaps in the availability of essential commodities”, according to a January 16th letter from the Global Fund to the Venezuelan Minister of Health. The funding will bring life-saving treatment and prevention services to thousands of people, and significantly strengthen the health system’s laboratory and surveillance capacity.

The grant follows a $5.0 million donation to Venezuela which was approved by the Global Fund Board in 2018. At the time the donation was made, Venezuela did not meet the usual Global Fund eligibility criteria but the donation was made on account of the country’s worsening humanitarian crisis, (see GFO article, October 2018). The donation was channeled through the Pan American Health Organization (PAHO) Strategic Fund for the purchase of antiretroviral drugs (ARVs).  In June 2019, GFO reported on numerous irregularities in the storage and distribution of different medicines throughout 2018 as revealed in community monitoring led by Red Venezolana de Gente Positiva (RVG+) (Venezuelan Network of Positive People) (see GFO 358).

In August 2019, the Global Fund Board announced that Venezuela would be eligible for a malaria allocation citing a clause in the Global Fund’s Eligibility Policy whereby the Fund’s malaria partners may recommend that a country which is not normally eligible for Global Fund support, become eligible in the event of a significant resurgence in malaria cases (see GFO 362, August 2019).

According to data from the World Health Organization’s 2019 World Malaria Report, in 2018 there were 747,247 suspected new cases of malaria in the country. Technical experts contend that Venezuela accounts for 51% of all malaria cases in the Americas. A further 14 million people are estimated to be at risk, and the number of malaria deaths has increased nearly eight-fold since 2010.

Additional Safeguards Policy

The Global Fund approved the funding at its November 2019 Board meeting. The Secretariat, though supportive of the allocation, has taken note of the extremely challenging operating context in Venezuela and this is reflected in the design of implementation arrangements for the malaria allocation.

Venezuela has been classified by the Global Fund as a challenging operating environment (COE). As such, the malaria grant will be managed under the Additional Safeguard Policy (ASP). The ASP is a set of measures that the Global Fund introduces whenever “the existing systems to ensure accountable use of Global Fund financing suggest that Global Fund monies could be placed in jeopardy without the use of additional measures.”

According to the allocation letter, the Global Fund will coordinate the development of the funding request, which must be submitted to access the funding. The Global Fund will also appoint a United Nations organization as the Principal Recipient to manage the grant, and will select any sub-recipient implementers, depending on the design of the grant.

Domestic Financing

The Global Fund stipulates that country stakeholders should work closely with partners and relevant ministries to strengthen domestic financing. When interviewed, Jorge Saavedra, Executive Director of AHF Global Public Health Institute and member of the Global Fund developing country NGO delegation, who has visited Venezuelan health facilities and observed the magnitude of the crisis first hand, said that the expectation of increased domestic financing was not realistic. He said it might take the form of “probably ‘in kind’ – some labor force and the use of facilities,” he said, suggesting that a non-monetary contribution is a more likely proposition, given the economic situation and the lack of urgency demonstrated by the government to tackle the epidemic.

Venezuela has been hit hard by the economic crisis marked by hyperinflation, plunging oil production and mounting debt. In 2018, Venezuela spent less than $1 per person at risk in malaria control programs, less than countries like Guyana or Haiti, and the vast majority of that money came from international organizations, highlighting the government’s systematic negligence. The anticipated shortfall of more than $12.5 million risks a deepening malaria crisis in Venezuela and the region.

Prioritized country needs

In addition, the Global Fund expects that the funding request should be aligned with country needs and National Strategic Plans and program reviews. Speaking to GFO for this article, Dr. Leopoldo Villegas, a Venezuelan doctor and researcher says that while a Master Plan for Malaria does exist, there are no resources allocated towards it. In his view, it is merely a “shopping list” of interventions based on WHO recommendations, not an actionable plan that reflects the massive scale of the need. “What the government and current stakeholders are doing is not having an impact. “You need to control the epidemic. If the Global Fund wants to have impact, they will need to control the epidemic first. You can have the best system doing diagnostics and treatment but to control your epidemic you need to understand the dynamics.”

Access to information

The Global Fund also cautions that it expects to have access to information that would allow for informed decision-making throughout the grant cycle. The government of Venezuelan president Nicolas Maduro has been criticized by Human Rights Watch for its failure to provide information of public interest, such as accurate statistics on the country’s health crisis.

Meaningful engagement of communities

A recent press release by the International Council of AIDS Services Organisations (ICASO) and  Accion Ciudadana contra el SIDA (ACCSI), a Venezuelan AIDS organisation,  applauds the news of Venezuela’s malaria allocation from the Global Fund. “Venezuela’s malaria allocation is a significant milestone in the sustained advocacy efforts from technical experts and community activists from Venezuela, and their allies around the world,” said ICASO’s Executive Director Mary Ann Torres. “Together, we pushed the Global Fund to make the eligibility exception. Now, we will continue supporting our partners in country to ensure transparency and accountability for these hard-won resources.”

Alberto Nieves, Executive Director of ACCSI said “we are very happy with the Global Fund’s decision to support malaria initiatives and protect the lives of some of our country’s most vulnerable. We are happy that our community monitoring is being taken seriously and we commit to continue to monitor the situation. We also welcome the decision of the Global Fund to invest directly in Venezuela, where the emergency is happening.”

Venezuela has very little experience with the Global Fund owing to its classification as a middle-income country, which made it ineligible for grants until now. As a result, Venezuela does not have a Country Coordinating Mechanism (CCM).  According to advocates working in Venezuela, establishing one now will be impossible, amid the escalating political crisis marked by the government’s targeted campaign of violence, intimidation and repression of human rights defenders. The experience of alleged widespread irregularities with the prior ARV donation (medicines arrived in country but distribution was delayed) foreshadows serious challenges ahead. The implementation of the grant will nevertheless require coordination with the government and engagement with civil society and affected communities.

There is widespread doubt that funding request development and grant oversight will be multi-stakeholder and democratic in nature. Advocates have suggested that in the absence of a CCM, an alternative governance mechanism should be put in place. As it is, there are few communities working on malaria and knowledge of the Global Fund is virtually nil. There would need to be a plan to build civil society’s capacity to engage in the grant-making process. 

Lastly, based on the experience of ARV donation approved exceptionally by the Fund in September 2018 (see GFO 358) , it will be important for the Global Fund and others to invest in community-based monitoring. “There is a need to involve communities to monitor to services are done and to be confident that resources are being delivered to the communities that are affected,” says Dr. Saavedra.

Further reading from previous GFOs:

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