Goliath attacks back: Bureaucracy, the local capacity abilities and popular participation following Bolivia’s Global Fund project approval Background: David and Goliath2
Some readers may remember my first article about the Global Fund in Bolivia. I told a story about thesuccessful involvement of individuals who were HIV positive, at a time when the CountryCoordinating Mechanism (CCM) was excluding us. At that time, I identified the giant that we had tofight as the Global Fund itself. At that moment the Global Fund (GF), seemed so powerful andentirely inaccessible to us, it seemed like a giant. However, once we got involved in the CCM, theproposal became real and it was approved. However, we did not realize at the time that our strugglesand the real fight were only beginning.
Today, eight months after the Bolivian Principal Recipient (PR) has received the funds, we realizethat Goliath has come to Bolivia. A new bureaucratic giant has been born with the project approval,and now the fight is even more difficult. We have to deal with our own Bolivian colleagues in the PR. At the same time, we must now participate in the Bolivian GF project as part of an “integratedproposal.” We are often seen as enemies of the country, as result of our constant advocacy and andnumerous petitions in national and international arenas. However, this giant is more powerful thanthe other. This is a local in-country bureaucratic system that has been created with the GF proposal. I am going to share my concerns about this native Goliath. Who can we blame for this giant?
In this paper I do not pretend to blame the Global Fund or the people working in the Global Fundproject in Bolivia for the existence of this giant. I understand that all of us in Bolivia, those taking partin the preparation of the proposal and the implementation, are responsible for the giant’s growth. This is a side effect, or adverse reaction that comes with the existence of a large amount of money,while the ability for team work does not simultaneously exist in a way that corresponds to the fundsavailable.
1 Gracia Violeta Ross Quiroga is a Bolivian woman living with HIV. She studied Anthropology in the University of San Andrés UMSA in La Paz- Bolivia. Currently she is undertaking the course of Master Degree in Gender, Sexuality and Reproductive Health, with a Research Grant from the WHO in the Peruvian University Cayetano Heredia in Lima, Peru. She advocates for the human rights of people living with AIDS, specially those of women living with HIV. Ross is the Andean Representative of ICW (International Community of Women Living with HIV/ AIDS), Delegate of the Latin American Network of PWAS (REDLA) to the 3 by 5 working group (WHO initiative). She is also member of the Bolivian Network of PWA (REDBOL), and a member of the Steering Committee of the Global Coalition on Women and AIDS (a UNAIDS initiative). She is the Focal Point in South America for the Global Youth Coalition against AIDS, and a member of the International Advisory Committee of BRIDGE.
2 Readers can find the complete original article: David and Goliath: PWAS and the Global Fund CCM in Bolivia in theGlobal Fund Observer Issue #32 www.aidspan.org/gfo/docs/gfo62.pdf
Side effects from the Global Fund project in Bolivia
I can see some undesired side effects of the GF project in Bolivia. I cannot say if these side effectshappened because we did not have previous experience working together, or came as result of thegreed that was created for the money of the GF. Side effect 1: Division of the movement of HIV positive people. We did not image that the money we had been requesting for many years which we knew was needed for an effective solution, was going to divide the movement of HIV positive people. In Bolivia, this division happened when we had to choose whether to present proposals as a single network or as regional groups. To have a single national project of the PWAS as an integrated proposal was going to make the accountability processes more clear. If we had separate groups of PWAS having projects by themselves, without a unified national network perspective, it was going to be more difficult to ask for accountability, because these groups could claim they did not have a network proposal but a private proposal.
REDBOL, the Bolivian Network of HIV positive people, is trying to keep the groups united despite thedesire of some leaders to have their own access to the funds and contracts with the GF project. These kind of problems happened not only in Bolivia but in many other countries in Latin America. The problem started when some PWA or groups of PWA decided to write proposals in consortiumswith other NGO or institutions. This fact is not harmful itself, but it becomes dangerous, when thesegroups or individuals lose the PWA network perspective due to the prospect of receiving the money. Side effect 2: Excuse the government in their national response to the pandemic. As people coming from the civil society movement, PWAS always demanded the governments create policies to respond the pandemic. These policies had to include support of institutions like the Health Ministry, but also come with commitments from the Finance Ministry. The GF monies were supposed to be complementary resources for the fight against AIDS at country level, but nowadays some governments are actually excusing themselves of the response, saying “we are waiting for the GF to buy the medications” or similar responses.
This is a serious problem. We have had previous experience with the international cooperation inBolivia. As long as the project was implemented, there were workers, activities, international supportand national commitment to the issue (whether the issue is development, women’s health, etc.). Once the project was over and the cooperation agents were gone, only abandoned buildingsremained for the country. Of course not all development projects had this sad ending, but thissituation was true in several projects. The main problem with these projects is that they did notinclude local people and they did not build local capacities, in order to develop a sustainable strategyfor the activities to continue after the project was over. It is unbelievable how we did not learn thislesson after so many bad experiences. Side effect 3: Strengthening vertical structures. One of the most terrible side effects of the GF in Bolivia, is the strengthening of already existent vertical structures. In Bolivia most of the political decisions are negotiated in La Paz, the political capital of the country. This is one of the reasons why we now have problems regarding the permanence of the current President3. Cities that were
3 See current news of Bolivia in www.larazon.com
traditionally excluded from policy making are now claiming for autonomy. Some of the sameproblems happened with the GF project in Bolivia.
The most negative character of this side effect is that the CCM started to work as a mechanism ofthe government and not as a mechanism of the country. We used to have vertical authorities of thegovernment, and now these vertical structures are leading the CCM. They make decisions thatexclude the input from the civil society representatives.
This situation was worsened by the political instability in Bolivia. To date, the Health Minister haschanged, and we have had 3 different CCM presidents at least, even though the implementation isjust beginning. Side effect 4: Concentrating on indicators while forgetting participatory processes. If the GF is rigid in the indicators, some of the projects will focus on having very good indicators but forgetting the participatory processes. This has not been the experience of Bolivia, because have yet to implement the project, but I have seen this side effect in other neighbor countries. Other countries had established ambitious goals, but now after one year or more of the implementation process, they need to review their goals and indicators because they are not realistic. Side effect 5: Creating additional bureaucracy limiting access to treatment and care for HIV positive people. The worst side effect of the GF project in Bolivia and other countries in Latin America is that it created additional bureaucracy for the access to treatment and care for HIV positive people.
This is my own experience trying to have access to the antiretroviral medication in Peru. Since July2004, I have tried to receive ARV drugs through a program implemented with money from the GFproject in a Peruvian hospital. As the program demands several requisites in order to enter, Ineeded to provide several interviews with different specialists. I had two interviews with thepsychologist and consequent evaluations, one interview with the social worker, one interview with thenurse and one with the nutritionist. I also needed several medical tests to examine the ability of mybody to absorb the medications. All of these cost approximately $30 USD. I spent money going toand coming back from the hospital several times. I also needed to have an agent of support; this issupposed to be a person who is going to support the HIV positive person in the adherence process. However when I brought my agent of support to them, nobody explained her role, until we askedwhat was she supposed to do.
As I was studying in Lima, I was living alone and my family was in Bolivia, so I did not have anyrelatives or friends who could sign those forms. I asked my friend living with HIV to do the role ofagent of support for me. The technical team objected my choice, because the norm says that an HIVpositive person cannot support another HIV positive individual.
I think this is a ridicule regulation. Most PWA know that the best support comes from those that haveexperienced the same conditions that we have. I also asked what were they going to do if a couplecame and both of them were HIV positive, having no one else other than themselves. They said theywould get a volunteer to this role. However, what happens if they do not feel like sharing their status
with a stranger, a volunteer, but a stranger to them. The reality nowadays is that most PWAS get afriend to sign, but these agents of support, are not doing the role of support at all.
They also told me that during the first 3 months of the treatment, I had to go weekly to receive thetreatment and bring back the empty blisters of the medications. I was astonished and thought thatwas a very naïve way of controlling the adherence, so I told the nurse that I could also bring theempty sachets of the condoms I was going to use, if required. By saying this, I wanted the nurse torealize that it was a very simple and unrealistic way of finding out about the adherence. Some peercounselors even objected the possibility of me having medications in Peru since I am a foreigner. They said they had never discussed this point and some discussion may be required before havingreal access to the medications. For me, this meant more time without the medication.
After all these processes, that took over 6 months, while receiving my CD4 test showing 209 CD4cells, I was told that the medication I needed (Combivir and efavirenz) was not completely availablein that hospital. They had Combivir but not efavirenz. The medical doctor in charge told me that theynever received this medication, even thought they asked and complained several times with theHealth Ministry.
I was once more astonished. What were HIV positive people doing to have the complete ARVcocktail? I asked. They told me others are buying efavirenz themselves. I asked why this hospital didnot receive the efavirenz, since it was supposed to be purchased with the GF money. They did nothave the answer, but said that it was the responsibility of the Ministry of Health and the PR torespond to this question.
So, in the end, I still do not have real access to the medication. At least not in Peru, because ofseveral reasons, this medication that has to be bought with the GF money, is not available in thehospital I was attending. Not in Bolivia, because after 8 months of the disbursement of money fromthe GF to the PR, the implementation process is just starting and the ARV drug purchasingprocedures will take even more time before the access medicines can become real.
What do I mean when I say “real access”? With real access I mean the reality of having those medications in the hospital, so they can be provided to me without unnecessary delays and so many bureaucratic procedures; so that tomorrow I can drink those pills with my breakfast. That is not happening right now. I can understand the bureaucracy if there is access to the medication, but I cannot understand this kind of much unneeded bureaucracy. Lessons learned from the giant:
The GF project is also teaching us so much. Here some of the lesson I believe are crucial:
Lesson 1: To defeat the AIDS pandemic, we need not only funds but also the ability to work in coordination between different stakeholders. The governments always claimed that they could not response to the AIDS pandemic, because of the lack of resources. Today, we face the reality of having huge amounts of money for the HIV/AIDS fight. Some countries never had so much money for a single disease. Even though we have the money, the coordination and participation processes are not well organized. Most of the problems in Latin America have their roots in the relationship
between the Principal Recipient and the CCM and within both of these, between with the civil societyand those organizations that are going to implement the proposal.
The main barrier and obstacle in some countries in Latin America was the lack of experience incollaborative and coordinated actions between the government, the civil society movements, and theinternational cooperation agencies in the country.
I worry about those countries with GF projects under observation. After they have had the GF projectand it is not successful, not even credibility will remain for them, because they already had themoney and the coordination did not work any way.
In this sense, I wonder which is the major legacy of the GF project for these countries? I believe theGF needs to improve its monitoring methods. This is a must, because the situation is particular, wehave several countries that never had so much money, in addition they did not have previousexperiences working in coordination with other stakeholders. For the GF to abstain from control andto let countries alone in this process is a naïve action that directly ignores and denies the waydecisions are taken at country level. Most of the people in the countries are expecting more guidanceand support from the GF. Lesson 2. Transparency and accountability are needed at all levels and processes. Once the proposal is approved, the PR has total control of the communications with the GF, and the civil society looses important direct channels with the GF, which could be used to watch the accountability of new and ongoing initiatives.
In Bolivia and some countries in Latin America, transparency has not been the norm in all levelsgovernance and in the decision making process. In Bolivia, the Health Ministry designed severalpositions that were going to be paid for by the GF project, without having public selection process. Some workers of the Health Ministry resigned their jobs in order to have the GF consultancies. Somecivil societies groups had the same experience. There were not any public calls for positions, whileleaders appointed close friends for the jobs. I am not sure how many of the people working in the GFare really able to do the job they were appointed for. Because there was no evaluation process, thiscreates the risk of having people that do not have the necessary skills for the positions.
The civil society in Bolivia, particularly REDBOL and other NGOs protested about this decision,expressing our disagreement. The Health Ministry said we needed to implement the project as soonas possible; therefore, there was not enough time to select the staff in a normal public process. Aftersome letters and much public opposition, the Health Minister decided to change this decision.
As members of the civil society movement, we feel embarrassed for those groups of PWAS that didnot make a public call for the GF positions. Lesson 3: The Civil Society Movement needs to improve its abilities. Another important lesson from the GF project in Bolivia is the need to strengthen civil society groups to become serious institutions, able to administrate and implement projects like the ones of the GF.
Throughout this process we realized we needed to improve our abilities to design, implement andevaluate social projects. Our ability to work with the government and other decision makers at theinternational level also needs to be strengthened. Often, the groups of people with HIV/AIDSconcentrate on protests and denouncing the mistakes of the government. Only a few leaders areready to work in effective coordination with the government. Some leaders also need to learn that wecan still critique and analyze the government policies at the same time that we work with them. Someleaders in Bolivia now act more like employees of the government than members of the PWAnetworks. We do not need a condescending attitude towards the government but need to beproactive and have the ability to propose creative solutions. Lesson 4: The resources of international cooperation should not reinforce vertical structures. Some agencies of international development and cooperation do not even have the time and staf to visit the country. They rely upon what the government officially informs them about the country. Sometimes the civil society movements are not consulted for the project proposals.
Regarding the GF specifically, once the proposal is approved the PR has total control of thedecisions and communications to the GF. What if they PR is also at the same time some verticalrepresentative from the government? What if the CCM is understood as a governmental institutionmore than a mechanism of the country? If the GF strengthens vertical structures, then its contributionto the countries becomes a harmful for people at the grassroots levels, because their participationwill be limited more than before the project. We also have the problem of power and control offinancial resources in the middle is this situation, and this is something the GF has to think about.
As civil society movements, we need an open communication channel with the headquarters inGeneva. The GF cannot rely only in the information provided by the PR. Lesson 5: The PR needs to have an integral perspective, concentrate not only in the indicators but also in the participatory processes. We started to see the PR worried so much about the indicators and the possibility of loosing the GF project. In some neighboring countries, we saw the organizations desperately calling for more people to be on treatment or to attend the various workshops, in order to fulfill the goals established in the proposal. Some organizations may even make up fake participants and workshops in order to have the right indicators.
The government representatives of the GF project in Bolivia and other countries in Latin America areworried about the international perception of the CCM and the project. They are also afraid of thenegative consequences of the protests of the activists.
There should be an open space for all of us to discuss honestly and openly what is working wel andwhat needs to be improved. This is a learning process for the GF itself. There is fear to say what isactually happening in some countries, and some activists were prompted to keep quiet about theproblems. The GF partnership forum is functioning as space for discussion regarding the GF projectsin different parts of the world. However, most Latin American people cannot participate as long as itis only published in English. Lesson 6: The GF is not a bank. The GF is a financial institution with a social mission. One GF representative once told me: “think of the Global Fund as Citibank”.
I thought of this and realized that the GF is a financial institution that has some regulations it needsto survive. However, the GF is not a bank. A bank has the ultimate goal of profit. A bank wants toincrease its income and they do not really care for the people’s lives but for their money.
The GF cares for the people. The GF is supposed to save lives of those affected by Tuberculosis,AIDS and Malaria. This is the mission the GF received when it was founded.
I wonder if something changed in the process. Did someone decide to abandon this mission and make the GF like a bank? I believe most of us who were somehow involved in the GF projects know that we are working because we want to save lives. We are advocating for the GF to keep receiving the contributions of the participating countries because we do not want more people to die and suffer due to these three diseases. When did we loose this perspective?
Please, let’s remember the GF is not a bank. The GF is a financial institution with a social mission.
Think before the implementation
The panorama does not seem hopeful, but I believe in Bolivia we still have the opportunity to reviewthe way we are acting and we have the power to change the impact of the GF project in Bolivia. However we have to think carefully before implementing. Some of these questions may help us inrealizing what needs to change:
What will be the impact of the GF in Bolivia and other developing countries?
I have been discussing this question with some Latin American activists. A Peruvian woman said:
“The Global Fund could be like a Tsunami, a big force, but comes without control, soinstead of building it wil actually destroy weak structures”
These huge amounts of money, aren’t they needed in our countries? Yes they are. We need themoney of the GF but we also need the participatory processes and the technical support. If the GFcannot itself provide this support, other cooperation agencies like UNAIDS can.
How can such a big force (amount of money provided to the country) actually destroy the weakstructures in the country?
• Excluding those affected by the diseases due to several administrative ToR
• Closing channels of direct communication with the implementers at country level
What about the PR?
The responsibility of this actor is as important as the GF itself. The PR is the main candidate tobecome the giant Goliath of bureaucracy.
In Bolivia, in order to get the ToR for the proposals, the PR prepared a CD that had to be bought atthe price of 50 Bs. (50 Bs = $7 USD in March 2005). This CD was a requirement to presentproposals, this means every person or organization willing to present a proposal, had to buy this CDbut this requirement was not explained any where but in the CD itself. How were people going toknow they had to buy the CD? What is more questionable, what was the PR going to do with themoney collected with the sale of the CDs? Were the administrative costs were covered in theoverhead percentage? We asked these questions and did receive satisfactory responses from thePR.
The PR designed a very rigid document of Terms of Reference (ToR) for the sub recipients. The ToRwere so rigid that the first call for proposal was declared void. They had to make the ToR moreflexible fro the second call.
This was the moment when the GF in the country can actually exclude HIV positive people and othercommunity based organizations. None of the Community based organizations had the requirementsthe PR was asking in the first call. One of the direct negative effects of these rigid requirements wasthe delay in the whole project, as it had to take the time to have a second more flexible call.
The power the PR gets after the proposal is approved is quite important. If the PR is not in harmonywith the civil society, then it wil become a Tsunami force in the country, and it will actually harm thecommunity based organizations.
These questions may help in the examination of the role of the PR and the CCM role in the country:
• Is the GF project in Bolivia is strengthening REDBOL and other civil society organizations or
• Is it increasing the leadership of PWAS (as the GIPA principle dictates) and other civil
• Is it strengthening the countries abilities and capacity to respond to the three diseases or is it
• Is it making the access to treatment and care for HIV patients and those suffering with TB
and Malaria more accessible, or is it creating additional bureaucracy?
• Is it strengthening counterproductive systems and structures in the country?
• Are the resources going to benefit those who with experience working in with these diseases
or is it going to distribute the money between friends and influential people?
• Is the GF in Bolivia going to create a new elite that controls the decision making processes?
• What capacities will remain for the country after the GF project?
• Is there a list of how the proposals are going to strengthen the capacities of the country?
• Is the CCM working as a democratic institution of the country or as another traditional
• What is the role is of HIV positive people and others affected with the diseases in the CCM?
• How are the needs of communities represented and expressed in the composition of the
• Is the PR fulfilling its role efficiently or is it another bureaucratic institution?
• Why has the PR still not disbursed the funds to the sub recipients, 6 months after the
• What will the PR do with the interest that the GF money gains in the bank?
• Who is responsible for the six months delay in the implementation?
• How are the civil society and NGO groups going to be able to request of the project achieves
the goals if there is already a 6 months delay?
• What do we have in Bolivia after the GF project?
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