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Section: Nicaragua
Published: February 2005

Unacceptable Management of the Global Fund Project in Nicaragua

February 25, 2005

Dr. Josefina Bonilla de Bendaña
Executive Director

NICASALUD Network Federation
Managua, Nicaragua
Tel: (505) 270-0099 / 267-0182 / 277-0855

Dear Dr. Bonilla:

The organization you direct, NICASALUD, is the Principal Recipient for the Nicaraguan  Global Fund project.  The contract between NICASALUD and the Global Fund  was signed 7 October,  2003, and as of December of 2004, $1,7 million had been disbursed to your Agency. 

In a conversation I had with Fernando Campos, Donald Weil and Dr. Rafael Arana of NICASALUD,  on November 19, 2004, they insisted that most of the PLWAs in Nicaragua who required ARVs (a total of 65 at that time)  were receiving them under the Global Fund project.  They also stated that they were unaware of the fact that were possibly 1,000 people in advanced stages of AIDS,  without treatment, numbers that UNAIDS had published in July of 2004.

However, an article was published on February 18th, 2005   in the Nicaraguan press,  in which Dr. Enrique Alvarado A., from the Nicaraguan Ministry of Health, states that in 2003 there were 247 AIDS-related deaths, and in 2004 that amount  doubled, meaning that approximately 500 people died of AIDS last year!

If up to 500 people are dying each year in Nicaragua, how is it possible that only 70 or 80 require treatment?  For each person that dies of AIDS, there are an estimated 3 or 4  who require treatment.  That is to say that, currently in Nicaragua, there are about  1,500 to 2,000 people who urgently require ARV.

But Fernando Campos, Mr. Weil and Dr. Arana insisted in their conversation with me that they were unaware of these numbers. And since the conversation occurred, nearly four months ago, only  10-15 more PLWA have been placed on treatment. 

How is it possible that the Principal Recipient itself is not aware of the most  basic information that has an impact on the decisions it is making?

That is why we are requesting that the Global Fund investigate the ability of NICASALUD to manage this project, as it seems that those in charge are extremely uninformed about  issues relating to the life and death of many people.

How is it possible that we are almost in  March 2005 and there are still only 70-80 people receiving treatment (and 20 of these were people who should have been treated with Government funds and not Global Fund resources, since the government was already  paying for their treatment before the project began)?

I also believe it is important to know how much NICASALUD pays for  Viral Load testing   that is still  sent outside of the country to Guatemala  due to their inability to insure  having the necessary equipment in the country according to schedule.  (We have been told that test results take an average of two months to be available.)

There is still no equipment for CD4 testing  in Nicaragua, 17 months after the contract was signed!   

As I mentioned to Mr. Weil, Mr. Campos and Dr. Arana, last November, Honduras performs CD4 tests using the "dynabeads" technique at a cost of $5 per test.  Why can't  Nicaragua use such a technique?  On the contrary, it seems that NICASALUD is  seeking to purchase equipment and reagents which are  a lot more expensive, and which never have actually arrived in the country even though the money has been committed.  Not to mention unacceptable delays arising from having to send tests for Viral Load to Guatemala for test results.  Why is this? 

On what basis are these decisions made?    Doesn't the fact that there is no CD4 testing in the country, nearly a year and a half after $1.7 million was disbursed,  make a mockery of the whole Global Fund process?  In November,  Mr. Campos and Mr. Weil told  me that the  CD4 and Viral Load  equipment would be available  in January of 2005.  Now the Nicaraguan Health Ministry, in the February 18th article referred to above,  indicated that the equipment would be arriving "within three months."

It is for these reasons that I am forwarding a copy of this letter to Senior Staff of the Global Fund in Geneva.

We are aware that an agency such as NICASALUD earns an "income" by managing these funds, and quite frankly the incongruities I have observed in my various conversations with NICASALUD staff and Dr. Mathilda Roman and Dr. Brenda Mayorga (both members of the CCM for the Nicaragua Project) leave  a very bad impression related to the "transparent" utilization of the project resources.  We believe it is very important that the Global Fund perform a detailed and complete investigation of the management of project resources by NICASALUD, however, even more important would be that the Global Fund investigates  why only 70-80 people receive ARV when so many more need them.  

We are also  urgently requesting that UNAIDS and the PAHO support  Nicaraguan PLWA in regards to this extremely unjust situation they are facing, as yet  we have not yet received feedback from these Agencies   in regards to the situations that have been described above, nor are we aware of what interventions, if any, the international Agencies have initiated.

Agua Buena does not have the capacity to adequately evaluate  the problems that are causing the unacceptable situations which  we have described above.   We would like to point out that it is also not our intention to create a "crisis" similar to what happened with the Global Fund in Honduras, a short time ago.  In fact, we do not consider that terminating a Global Fund project is a viable solution for any country because those that lose the most when the project is terminated are the most vulnerable people who are the true beneficiaries of the project.  

Our target, on the contrary, is to "foresee" the problems that are arising in order for them to be resolved, before even greater problems arise.  But it is necessary to evaluate if NICASALUD is truly capable of fulfilling its tasks competently or if not, to identify another alternative so that PLWA can receive the attention they require. The situation in Nicaragua is clearly unacceptable and points out serious flaws in the Global Fund's ability to supervise the Nicaraguan project, as well as the inability of NICASALUD itself to carry out  the project.

We have been told repeatedly that the Global Fund is mainly a "financing agent" and that programs are "country driven."  Does this mean that $10.4 million (the total amount available for the Nicaraguan project) should be managed  without close supervision by the Global Fund, by an Agency such as NICASALUD  whose ability to respond to  the epidemic in Nicaragua is so dramatically inadequate, as to have created the situations such as those described above?   Meanwhile, national governments including Nicaragua and others,  use the Global Fund projects as a pretext to indicate that the problems related to the epidemic are being resolved, and therefore they do not assign further resources of their own.

We would welcome a response from yourself as well from the Global Fund.


Richard Stern, Ph.D.
Agua Buena Human Rights Association
Tel/Fax 506-234-4211


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