Recently, two HIV grants with NGO PRs have received an extension of funding while a TB grant that would have had an NGO PR never got to be signed. Why the different treatment? Because, says David Garmaise, the HIV grants originated from Non-CCM proposals, while the TB grant was submitted by the CCM and did not have the backing of the government. "The Global Fund sets the bar too high for Non-CCM proposals," Mr Garmaise concludes. "It discourages such proposals when it should be encouraging them."
The Global Fund Board has decided to extend funding for two HIV grants in the Russian Federation. The money will come from a bridge funding arrangement adopted by the Board in November 2011 to avoid gaps in service provision caused by the cancellation of Round 11. This is an interesting development in light of what has happened recently to proposals and grants involving Russia.
The principal recipients (PRs) for the two grants - one from Round 3 and one from Round 5 - are NGOs: the Open Health Institute and the Russian Harm Reduction Network. Both grants emanated from Non-CCM proposals. The Open Health Institute is PR for the Round 3 HIV grant. When Round 3 was launched, there was no CCM in the Russian Federation. The grant provides a wide range of services including antiretroviral treatment and monitoring, care and support for the chronically ill and their families, behavioural change programmes, condom distribution, counselling and testing, and the prevention of mother-to-child transmission of HIV.
The Russian Harm Reduction Network is PR for the Round 5 grant, which targets injection drug users. The proposal that led to that grant was submitted by a group of NGOs. Previous proposals from the CCM in the Russian Federation had not targeted this population, and the CCM was not planning on submitting a proposal for Round 5. At the time, the Global Fund agreed that the proposal from the NGOs addressed clear service gaps and met "a clear and compelling need."
Applicants are eligible to apply under the bridge funding arrangement only if they are also applying for funding under the Transitional Funding Mechanism (TFM).That means that the Open Health Institute and the Russian Harm Reduction Network (or the group of NGOs that applied originally) have applied for additional funding under the TFM. We don't know, of course, whether their proposals will be approved.
I am quite happy to see that the Board has approved bridge funding for both grants, and that the sponsors of the grants are applying for funding under the TFM. It means that vital services - particularly those targeting injection drug users - will continue to be provided. But there are several things about this situation that I find intriguing.
In 2010, the Government of the Russian Federation announced that the country no longer wanted to receive Global Fund money. The government said that the country's economy had improved to the point where the Russian Federation could become a donor to the Global Fund instead of a recipient.
This led to a rather strange sequence of events whereby the Global Fund first approved a Round 10 TB proposal from the Russian Federation CCM and then rescinded its approval by allowing time to run out for the signing of a grant. (See GFO article.) The proposal had nominated an NGO, the Russian Health Care Federation, to be the PR. The Global Fund said that any grant emanating from the TB proposal could not be implemented without the support of the government, and that the government no longer supported the proposal. (There is some uncertainty about whether the government ever wholeheartedly supported the proposal.)
The TB proposal was designed to provide treatment over a five-year period for 18,000 patients with severe forms of multi-drug resistant TB, as well as 1,700 patients co-infected with HIV and TB, 60% of whom are prisoners. The government said that it can provide these services without money from the Global Fund, but NGOs in the country are sceptical about whether the government will actually provide the services.
So, we end up with a situation where two HIV grants with NGO PRs have received an extension of funding, while a TB grant that would have had an NGO PR never got to be signed.
That seems rather strange. Why are these grants treated differently? The explanation appears to be that the HIV grants originated from Non-CCM proposals, while the TB grant was submitted by the CCM. Non-CCM proposals don't need to be supported by the government, but CCM proposals need to be supported by all stakeholders, including the government.
Incidentally, under new rules adopted by the Board in November 2011, the Russian Federation CCM is no longer eligible to apply for funding. This is because Russia is an upper-middle-income country and a member of the Group of 20 (G-20) economies, and because it does not have an extreme disease burden for HIV or TB. However, the "G-20 rule" applies only to proposals from CCMs; it does not apply to proposals from NGOs. This explains why the Russian Federation NGOs are allowed to apply under the TFM.
I find it disturbing that the Global Fund is not promoting the use of Non-CCM proposals - generally, not just in the Russian Federation - as a way of ensuring that services are provided to at-risk populations, such as sex workers, men who have sex with men, and injection drug users when these populations are ignored by national programmes. This has been recommended on several occasions by the Global Fund's own Screening Review Panel (SRP), the group that reviews applications to ensure they meet the eligibility criteria. In its Round 9 report, the SRP said:
"The non-CCM application option remains an important opportunity for groups marginalized as a result of severe stigma and discrimination in government policies, particularly regarding proposals addressing HIV/AIDS... It is clear that more guidance is needed from the Global Fund on when a non-CCM application is appropriate, and on what documentation is necessary to support a request for funding outside of the CCM model."
Making more use of Non-CCM proposals has also been recommended by the Technical Review Panel (TRP), the group that assesses proposals for technical merit. And, in November 2010, in a commentary in GFO 133, I said:
"It is evident that in many countries, the needs of key populations are not being addressed by the national response... It is time for the Global Fund to make some changes to the eligibility criteria for Non-CCM proposals so that civil society organisations can help fill this gap."
Unfortunately, there are no signs that the Global Fund intends to move in this direction. It is true that the Fund created a pool of money for proposals targeting most-at-risk populations (MARPs) at the start of Round 10. But, like all proposals, MARPs proposals usually have to be submitted by CCMs. The Global Fund sets the bar too high for Non-CCM proposals. It discourages such proposals when it should be encouraging them.
David Garmaise (email) is the editor of GFO.