Three Takeaways from the Latest Request to the Global Fund’s Board for Aid to Venezuela

Venezuela’s upper-middle-income country status has impeded its access to global health assistance even as its once world-renowned health system has fallen to pieces. In May 2018, however, the Global Fund, a multilateral donor focused on ending AIDS, malaria, and tuberculosis as epidemics, introduced a new approach to non-high-income countries ineligible for aid but in crisis that paved the way for two rounds of support to Venezuela. The first round gave $4.9 million for the procurement of antiretrovirals (ARVs) and $100,000 for monitoring efforts by civil society organizations. The second round, approved late last year, allocates $150,000 for monitoring efforts and $5.85 million for the procurement of HIV, malaria, and tuberculosis commodities. Thanks to the new approach, Venezuela is also now eligible for malaria-related funding in the 2020-2022 allocation cycle.

The Global Fund deserves substantial praise for its unprecedented aid to Venezuela, but the transparency around that support deserves recognition — and analysis — too. The publicly available proposal for the second round of support includes an update on the first round of funding as well as descriptions of several health-sector-specific challenges to operating in Venezuela. The details of those challenges present a critical learning opportunity given the limited information available about Venezuela’s health programs amidst an outsized need for aid. I offer three main takeaways from the second funding proposal and consider their implications for the future of health aid in Venezuela.

Takeaway 1: The initial funding for Venezuela was not governed like the Global Fund’s typical investments, and those differences will carry into the second round of support

The initial support Venezuela received differed from the Global Fund’s standard operating model in several ways. First, the Venezuelan government did not submit an official request for assistance; the proposal for support came from within the Global Fund. Second, the support was structured as a donation instead of a grant. That structure could explain why so many of the Global Fund’s traditional assurance and accountability mechanisms, including independent audits and investigations, did not apply. Perhaps most importantly, accountability for the ARVs purchased by the Pan American Health Organization (PAHO) for Venezuela largely ended once PAHO delivered the commodities to a local warehouse. The national AIDS program managed the distribution of ARVs from that point forward, but had “no formal obligation to complete this distribution,” and the Global Fund could no longer seek recourse for “the loss, destruction, or misuse” of the ARVs. While these implementation arrangements did not address the risk of diversion and will remain the same for the second round support, it is important to note that any malaria-related funding Venezuela receives as part of the 2020-2022 allocation cycle will be subject to the Global Fund’s standard policies and processes.

Takeaway 2: Even external monitoring and accountability efforts have faced significant barriers

The second funding proposal backs up longstanding claims the government often hampers transparency and accountability efforts. Tensions between the government and civil society representatives allegedly resulted in the latter’s absence from the central warehouse during one of the ARV deliveries. The proposal also notes the government has been “reticent to engage and allow civil society presence in pharmacies,” which would have been crucial given the government did not have to distribute the ARVs purchased with Global Fund support. The broader scarcity of official health data and allegations that access to some services is politicized makes external monitoring efforts even more essential. Those accusations have plagued whole programs like the food subsidy program Los Comités Locales de Abastecimiento y Producción, as well as the handling of individual refugee and migrant cases. Civil society groups working on HIV/AIDS have also documented illegal raids by security forces that disrupt operations.

Takeaway 3: Venezuela’s procurement process remains weak and the country continues to rely heavily on donations of medical supplies

Civil society groups warned back in 2017 the government was risking a total stockout of ARVs by not starting the procurement process on time. The recent funding proposal suggests timely and adequate procurement remains a challenge. Stockouts of tuberculosis drugs are expected to start before any Global Fund support can offer relief. Further, the government had not purchased any HIV-related commodities by October 24, or even indicated it was planning to do so despite projections predicting stockouts by mid-2020 without intervention. Venezuela’s procurement woes are particularly troublesome as the numerous donations of medicines and diagnostics that have arrived remain insufficient to meet demand, according to the Global Fund.

Lingering questions on the future of health aid in Venezuela

The recent funding proposal sheds some light on the mostly opaque aid process in Venezuela, but it also raises several important questions. For example, to what extent do the transparency and operating constraints on the ground dissuade donors without eligibility criteria from providing aid to Venezuelans? Is it possible to obtain any more transparency from the Venezuelan government on health issues? PAHO, the World Health Organization, and UNICEF have managed to regularly publish immunization statistics for Venezuela despite the issues the data show.

Venezuela’s Vaccine Coverage Rates in 2018

Note: DTP 3 refers to the third dose of the diphtheria-tetanus-pertussis vaccine; MCV 1 and 2 to the first and second dose of the measles-containing vaccine; and Polio 3 to the third dose of the polio vaccine.
Source: WHO/UNICEF Official Country Estimates of Immunization Coverage for the Year 2018. Updated December 10, 2019. Retrieved from https://www.who.int/immunization/monitoring_surveillance/data/en/.

Are the biggest problems poor coordination and parallel systems? An exhaustive “Master Plan” exists for addressing issues related to HIV, malaria, and tuberculosis in Venezuela. It remains unclear what organizations will lead the development of similarly comprehensive plans, disease-specific or otherwise. The United Nations’ Humanitarian Response Plan for Venezuela is far broader in scope, focusing on health, food security, nutrition, education and more, but has less detailed action items compared to the Master Plan. Donors and aid agencies also often have overlapping mandates and activities, which can cause confusion. For example, the second funding proposal included cost estimates for pediatric ARVs because the Global Fund Secretariat and its partners were unsure whether UNICEF would continue to cover those costs in the future.

Understanding and addressing why donors have been so slow and hesitant to provide aid for Venezuela should be a top priority given the outsized need for health assistance. Only 34% ($74.9 million) of the United Nation’s Humanitarian Response Plan for Venezuela and 25% ($15.1 million) of the health-specific ask under that plan has been funded (an additional $15.5 million was shared across multiple clusters/sectors). Even the Venezuelan refugee crisis is not bringing in funds commensurate with the level of need. According to a recent analysis, the global community has spent $125 per Venezuelan refugee compared to $1,500 per Syrian refugee despite Venezuela experiencing a comparably sized exodus of around 4 million people.

Conclusion

Stories about Venezuela’s poor health outcomes have abounded for years now, but the need for health assistance has continued to exceed supply. The Global Fund should get high marks for its commitment to transparency and willingness to provide aid to an otherwise ineligible country. However, the crisis in Venezuela requires much more from the international community. Donors on the sidelines should take a close look at the Global Fund’s documents, which clearly describe commodities in dire need of funding (e.g., pediatric ARVs), as well as opportunities for improving transparency on the ground (e.g., more funding for civil society organizations). Additional work is also needed on how best to address the health worker shortage in Venezuela, which no amount of volunteers and no single organization can sustainably solve.

Photo by Marco Verch on Flickr

Roxanne Oroxom

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