It has been nine years since the Global Fund first established. During its journey, the Global Fund has become the main financier of programs to fight AIDS, TB and malaria with approved funding of US$ 21.7 billion for more than 600 programs in 150 countries throughout the world. The Global Fund is a public-private partnership and international financing institution. This partnership between governments, civil society, the private sector and affected communities has been called as an innovative approach to international health financing. The Global Fund’s model is based on the concepts of country ownership and performance-based funding, which means that people in countries implement their own programs based on their priorities and the Global Fund provides financing on the condition that verifiable results are achieved. To date, programs supported by the Global Fund have saved 6.5 million lives by providing AIDS treatment for 3 million people, anti-tuberculosis treatment for 7.7 million people and 160 million insecticide-treated nets for the prevention of malaria. Beyond these three areas, the Global Fund also had contributed in achieving the Millennium Development Goals 4 (reduce child mortality) and 5 (improve maternal health) which have strong linkage with the three diseases mentioned. The Global Fund works in close collaboration with other bilateral and multilateral organizations to supplement existing efforts in dealing with the three diseases.
The Global Fund was founded on a set of principles, which are fully described in the Global Fund's Framework Document, that guides everything from governance to grant-making:
While the mechanisms seem to be flawless and ideal, we cannot rely on the national report for facts without asking the constituents. The people who are supposedly get the direct benefits from the program itself. It is not a secret that many times what happened on the ground is not as perfect as it is described in the report or on the paper. Take Indonesia for example. The country spreads from west to east, consisting of more than 17 thousand islands. Until October 2010 reported and documented AIDS case in Indonesia is 24,131 with 4,158 new cases. With a rather complicated geographical positioning, does the Global Fund program run smoothly and ideally in all 33 provinces of Indonesia? Does the program have great impact to the Key Affected Populations?
Aries is a peer educator from Central Java, he is nurturing a support group in his locality. As far as his concern, the Global Fund program in his area is limited to provision of ARV, CD4 check and operational cost for health care service providers. Even though since the Global Fund project was launched in 2009 the AIDS mortality rate had dropped to as low as zero in his area, it does not mean that the program was run ideally. Aries regrets the inequality of implementation. For Central Java itself, only selected cities and districts enjoy the financial support from the Global Fund while others are still struggling. Not only that, but in his area, Aries found out that the target groups funded by the Global Fund are merely sex workers, PLHIV and IDUs. Women are included in the PLHIV group while children and youth are not specifically mentioned, let alone gay men and transgenders. He also expressed his concerns regarding the monitoring system of the implemented programs. So far, the documentation only covers the quantitative data and there are no follow ups.
Oldri, a Program Manager in Indonesia Positive Women's Network has slightly similar opinion. From her observation, the implementation of the Global Fund program in Indonesia is considerably fine when seen from the perspective of achievement of target groups and intervention. However, the achievement is not accompanied by adequate quality of service for the Key Affected Populations. In short, the program has been successful quantitatively but not necessarily qualitatively. The success in Indonesia cannot be concluded as ideal due to role shifting of the civil society and communities in supporting the Heath System Strengthening, which initially is the role of government in the effort of fulfilling the Right to Health of the citizen. According to her, the objectivity of programs funded by Global Fund is also low and sporadic because the target is specific only to high risk group while due to the data from the Indonesia Ministry of Health in December 2010, 25% of the infected people are coming from general population. In this case, housewives, the group that is not considered as high risk population.
Dr. Bagus, a medical practitioner, feels that judging from the proposal that was created based on the National Strategic Plan, the multi-sectoral involvement that was introduced and guided by 3 PRs is a good innovative way to execute the action plan. This was expected to contain the epidemic in Indonesia. Nevertheless, several challenges and obstacles were spotted such as the quality of program, uneven program expansion, understanding regarding the philosophy of the program, sustainability and coordination. Quality of program has always been a big question because the high number of quantitative report on outreach, syringes distribution and condom distribution is not accompanied by proper quality of service or follow ups. This is also confirmed by Dr. Ramona from PKBI [Association of Family Planning Indonesia] and Dr. Wan Nedra from PBNU [The Central Board of Nahdlatul Ulama], the faith-based organization in Indonesia. PKBI and PBNU are both PRs of the Global Fund in Indonesia. They claimed that every programs funded by the Global Fund is focusing solely on the quantitative aspect and almost none for the qualitative aspect, which creates dilemma for the program implementor [the SRs and SSRs]. Wan Nedra appraised the Global Fund for its organized structure and guidelines, however, she strongly feels that capacity building and advocacy should be included as the essential core elements that are covered by the Global Fund. Given the geographical location of Indonesia, Wan Nedra also addressed her concerns that the Global Fund can only be implemented in certain areas of the country, PBNU specifically experienced that it is impossible to conduct the programs in Maluku, Southern Borneo and Lampung due to the characteristic of the locals, communication issue and the recurring internal conflicts in those areas. Ramona mentioned that PKBI run its Global Fund-funded programs only in 12 provinces and 68 sub-provinces [districts]. Mainly Java, most of Sumatra and Bali are the areas that furnished with the Global Fund-funded programs.
On the other side, the question of sustainability is also lingering. The existence of Global Fund had been misinterpreted by the government and used as an excuse not to allocate certain amount of fund for HIV/AIDS prevention, treatment, care and support in the national or local government budget. The fact that Global Fund is only temporary seems to be disregarded and neglected. The government most likely denies the fact that sooner or later international funding will be discontinued and countries are expected to be independently finance their own needs accordingly. The dependency of the government on the foreign aid is rather appalling.
What most people are not aware of is various shocking circumstances regarding the PRs in Indonesia. One of the incidents was that PKBI, as one of the PRs for Global Fund, received serious accusation of Human Rights violations during the Global Fund Round 8. The allegation came from their SSR field officers in Tegak Tegar Foundation who claimed that they had to undergo mandatory urine test that resulted contract termination. Four people were terminated due to their urine tested positive on drug use and they filed a complaint to the National Commission on Human Rights. There is no further follow up or clarification from the Global Fund Country Coordinating Mechanism [CCM] nor from Technical Working Group [TWG] whatsoever regardless the summon letter was sent by the Commission on Human Rights. Nevertheless, the incident was scandalous and causes a lot of resentments from the grassroot community, especially when PKBI once again was selected as the PR for Round 11. Apart from that, the practice of money politics were also found. Cases where clients are compensated by certain amount of so-called "transport money" in order to undergo VCT were something that people can find on daily basis, especially during Round 8. This practice had in fact diluted the initial definition of VCT itself. Certain group of people were not doing it voluntarily, anymore, but merely for financial reason. The trigger for this practice to occur is presumably the high number on target that the field officers need to achieve with lack or no capacity building. At the end, the field officers were frantically trying to fulfill the target and somehow work ethics seemed to be thrown out of the windows. It was somehow a mutual symbiosis; the client needs extra money, while the field officer needs to reach the target. Nothing else matters, but to reach the target.
On the other hand, PBNU as a moslem faith-based organization is also facing resentment and doubts from the community. Hartoyo, General Secretary of Our Voice, addressed that PBNU as the PR of the Global Fund is perceived by the LGBTQ community as being highly reluctant in executing the programs for LGBTQ and sex workers despite the fact the fund had already been transferred in and one of the performance indicators for the current round is to focus more on gay and transgender group. Even though Wan Nedra declined that PBNU is acting reluctantly, criticisms are still flowing in for them through mailing lists and discussion forums mentioning that PBNU, despite its responsibility as the PR for the Global Fund Round 9, is still not opening itself to outreach the LGBTQ community. This sort of friction caused a big question mark on the process of selecting PR in Indonesia. Now the community is starting to question the eligibility and what is the mechanisms in place to be selected as PR. Eventually the community demand that the Global Fund implement some sort of fit and proper test to all applying organizations to see whether or not they deserve to be PR, SR or SSR of the Global Fund.
As for the National AIDS Commission, Nafsiah Mboi, the Secretary, addressed that the implementation of programs funded by Global Fund is actually getting better. After several unfortunate incidents with the Global Fund in Indonesia, now Indonesia finally reached its peak time. This is based on the 'A' ratings of the PRs in Indonesia. For Round 11, Indonesia gets 4 PRs which consists of 2 government institutions [National AIDS Commission and the Ministry of Health] and 2 Civil Society Organizations [PKBI and PBNU]. Nafsiah emphasized that the cooperation and coordination between the government and Civil Society Organizations needs to be improved and strengthened. Especially because all parties need to realize that no one can work alone, therefore, good partnership is required in order to achieve the national goals in HIV prevention. Nafsiah realizes the dynamic and frictions within the NGOs, government and the PRs of Global Fund. She claims that resentments will always occur no matter what, and that the most important thing at this moment is to continue the work and ensure that the fund is being utilized effectively.
Overall on paper the achievement of target from programs funded by the Global Fund in Indonesia may display rapid progress. But if we go around talking to people from grassroots who are supposed to be the beneficiaries of this programs, there are still a lot of resentments toward the transparency issue within the Global Fund CCM. Even though the civil society has representatives in the CCM, there seemed to be a breakdown of communication. A lot of information regarding the Global Fund are not widely disseminated. It is always interesting to have both sides of the stories. Lack of transparency, gender-sensitive approaches and capacity building as well as quantitative-base report has been the greatest obstacles with no resolutions. Even though a lot know that the Global Fund initially carried out a noble mandate, they need to realize that the current practice on the field could be totally different. The uniformed complaints regarding no budget allocation for advocacy and capacity building, as well as regarding the quantitative target only should be considered as strong suggestions because at the end of the day, those who are implementing the plans are the ones who know what is best for the community. A more comprehensive and qualitative mechanism is desirable, not just a matter of achieving the targeted numbers. People need follow ups. They are yearning for friendly, gender-sensitive and indiscriminate services. And furthermore, the communities in Indonesia refused to be seen only as "numbers" that beautify the statistic reports.
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