Published: July 2003
The Dominican Republic Global Fund Project: An Open Letter from Eugene Schiff, of Agua Buena, replying to BRAD HERBERT, GFATM Chief of Operations
2 July, 2005 Mr. Brad Herbert,
Chief of Operations
The Global FundGeneva Switzerland
Dear Mr. Herbert:
Thank you for your timely response (below) to our report on ARV access and the Global Fund in the Dominican Republic. It is our hope that the urgency of these concerns reaches and is appreciated by those with the power to pressure for real change on the ground.
However, your brief reply is somewhat disconcerting. You mention that you will be visiting the Dominican Republic in early July, and are interested in finding out the "real" causes for the delays mentioned in our report. Yet the "real" causes for the delays have been well known to the Global Fund now for 30 months, and are related to the Global Fund Board's own policies and decisions. It was the Global Fund's promise to provide funds for ARV treatment that caused the government and other agencies to back off from assuming these needs and scaling up treatment access during the past two years. It is the Global Fund that specifically required the selection and creation of a national intermediary bureaucracy to become the recipient agency. It was the Global Fund that approved the selection of COPRESIDA, which thus far has proved to be an extraordinarily inefficient and ineffective (and some argue very corrupt) agency to receive and manage nearly $50 million dollars for the HIV/AIDS grant over five years. Needless to say, it has been the Global Fund that has delayed the disbursement of a significant amount of funds from January 2003 until June 2005.
Like many agencies intimately connected to and influenced by the political patronage of the executive branch of the Dominican Government, the executive leadership of COPRESIDA has changed at least three or four times since the Global Fund appeared. Yet each change seems more like a new coat of paint, which is meant to appease detractors, excuse the lack of progress, hide major structural flaws, and provide a glittering superficial cover in order to collect the millions of dollars in funds. Press releases and speeches are given, pictures are taken, agreements and faxes are officially sent, stamped and signed, yet little really changes.
Some have commented that in previous visits to the country by Portfolio Managers and Global Fund Board Members, these overworked individuals have simply flown in, racked up frequent flier miles and hotel points, met with COPRESIDA officials in Santo Domingo, dealt almost exclusively with their concerns and views and the Global Fund's own stringent indicators and requirements, and flown out. In some circumstances, it has been argued that when others agencies and individuals have attempted to raise concerns about the process to the Global Fund, the sources of these complaints have been leaked backed to COPRESIDA, and this actually ended up sabotaging national dialogue and the Principal Recipient's willingness to share information with other local and international organizations.
I would like to ask you a few difficult but important questions. For instance, in your visit to the Dominican Republic, will you be doing anything to ensure that all people living with AIDS in the Dominican Republic have access to a CD4 test to determine if they need antiretroviral medicines this year? How will poor people be able to access these tests since the government does not have its own lab capacity and the only private labs that perform these tests are in the capital, Santo Domingo? Or will this continue to be their own responsibility?
When will ARV medicines become available to residents of the poor rural town of Higuey, which is quite close to the beautiful beaches and famous luxury villas and resorts of the South-eastern corner of the island? When will people living with AIDS who are sick and dying in the town of Elias Pina, near the Haitian border, ever be able to access ARV medicines that have long been promised and could relatively easily be delivered to them, just as thousands of rural Haitians are able to receive them thanks to innovative projects in towns across the border? When will residents of the rural bateyes, and hundreds of thousand of Haitians living in the Dominican Republic ever be able to access comprehensive HIV/AIDS service and lifesaving ARV medicines without fear of being repatriated back to Haiti?
When will people living with AIDS in the Dominican Republic be able to access an affordable viral load test, just like people living with AIDS have been able to receive for years in Geneva? When will the treatment sites here be able to eliminate their waiting lists and provide ARV treatment to all those who need it? When will the Global Fund allow for all clinics and hospitals to be able to provide people living with AIDS with the condoms they need or with daily cotrimoxaxole pills for that cost only six dollars per year just as funds are available for executive's salaries, health care, taxi rides, hotel stays, generous travel allowances, and first class airfare? What are the true priorities of the Global Fund?
An indication of the government's commitment to these issues came during a presentation by one COPRESIDA official at a recent conference on HIV/AIDS in Haiti and the Dominican Republic at Columbia University in New York in April this year. He commented that the funds from the US Government's President's Emergency Program for AIDS Relief (PEPFAR) in Haiti should be made available to address AIDS treatment access for residents of the rural bateyes near the sugar cane fields in the Dominican Republic, suggesting that the needs of those living on the bateyes are not the problem of COPRESIDA or the Dominican Government. Is $50 million dollars enough to provide treatment access in the Dominican Republic to those who need it and also fill the suit pockets of executives and managers? Apparently it is not.
During your visit to the Dominican Republic I hope there will be time to consider these issues in addition to the other Global Fund business, since the Fund and its official partner, Dr. Alberto Fiallo Billini who currently directs COPRESIDA, have in practice made little progress in addressing these needs and the needs of poor people living with AIDS in the Dominican Republic
That there has been scarce access to CD4 tests, fluconazole, ARV medicines, and even electricity to most of those who come to the Centro Sanitario, a public STI clinic which is one of the country's largest treatment sites and is just block away from the Presidential Palace in Santo Domingo, is a good indication of the real priority the Dominican leadership gives to HIV/AIDS and health care for the poor.
Also appalling is the situation in the overcrowded and poorly funded Padre Billini Hospital. This large public hospital, located in the historic Colonial District in Santo Domingo, is one of the few places that poor PLWA can sometimes be hospitalized, if they are lucky. Yet there is no isolation ward for those with AIDS to be separated from others with active TB, there is no access to ARV medicines for those who are hospitalized with opportunistic infections, no access to CD4 tests for those who are hospitalized, no regular access to fluconazole or many other essential medicines for opportunistic infections, despite the fact that COPRESIDA has received donations of these medicines and a project of nearly $50 million dollars to resolve these needs from the Global Fund.
As you visit the offices of COPRESIDA and are driven through the expansive and modern (at least for this island) Plaza de la Salud in Santo Domingo, which also holds the offices of UNAIDS and the Pan American Health Organization, and several large buildings comprising an essentially privatized hospital built with largely public funds, you may be surprised that nowhere in hospitals of the Plaza de la Salud are ARV medicines available through the National AIDS Program. This is yet another one of the idiosyncrasies related to the haphazard, insufficient, and illogical trajectory that the planned expansion of ARV access has followed. When you arrive, it may also be the case that a large shipment of ARV medicines is still sitting in the customs office waiting authorization for its removal, a process that often takes many weeks. In a country with over 10,000 people urgently needing ARV treatment access this year, these medicines should never even be sitting in customs or warehouses for such periods when they are needed by people in clinics and others who are dying in cities and villages throughout the country.
The Global Fund purports to be a country driven approach to solving the pressing health needs of AIDS, Tuberculosis and Malaria in the developing world. In the Dominican Republic the country's leaders and health authorities, unlike several of their more courageous counterparts in the region, have driven the vast majority of people living with AIDS to their death, both before and since the arrival of the Global Fund. What will be done to truly change this approach? The Global Fund's response to this question in the Dominican Republic and elsewhere will either save or sacrifice the lives of millions of people living with AIDS worldwide. A failure to change its approach and both identify and encourage effective and committed local partners will also determine the impact, success and survival of the Global Fund itself.
Caribbean Region Coordinator
Agua Buena Human Rights Association
Santo Domingo, Dominican Republic