Examination of Witnesses (Questions 619
- 639)
MONDAY 21 APRIL 2008
Ms Diane Stewart and Dr Stefano Lazarri
Q619 Chairman:
Good afternoon. Thank you very much for your time. Thank you very
much also for your written evidence, it was very helpful. We have
got about an hour now and we want to go through some questions
with you. These proceedings are being recorded and you will see
a transcript of them before they are published to enable you to
correct any factual errors. Also, if you feel after the event
that there are issues you would like to bring to our attention
or to clarify points which you did not bring up in the hearing
itself, please feel free to contact the Clerk and do so. Perhaps
I could start by asking you to introduce what you do. I know,
Ms Stewart, that you are the Head of Board and Donor Relations,
but perhaps you could briefly say what your two job descriptions
are.
Ms Stewart: Thank you very much. I am the Head
of the Board and Donor Relations Service at the Global Fund, which
means that I am principally responsible for all the governance
mechanisms, which includes the Board, its committees and all the
operations of the Board as well as the Partnership Forum, which
is our broader stakeholder grouping and representative group.
The other section of my team is responsible for public donors,
so governmental donors of whatever nature, and that is 98 per
cent of the funding of the Global Fund.
Dr Lazarri: Thank you. I am the Senior Health
Adviser in the office of the Executive Director. I am in charge
of keeping the technical dialogue and collaboration ongoing with
our technical partners, WHO, UNAIDS in particular but also the
World Bank and others, and in keeping the Global Fund updated
on scientific and medical developments, what is new and what is
happening, so that our policies and strategies are in line with
the most recent approaches, discoveries, developments in the medical
field. I also represent the Fund in a number of technical forums
and events, including some of the boards of our Partners—Roll
Back Malaria, Stop TB Partnership and others.
Chairman: Thank you very much.
Q620 Lord Desai:
Good afternoon. In your evidence you refer to the fact that there
are many health infrastructures in developing countries that have
some weaknesses, especially the shortage of health workers. Previous
people who have given evidence to us have suggested that one of
the reasons is that, since a lot of money goes into something
like HIV, that drains the health systems of health workers who
would be useful otherwise. You are one of the big, big donors.
How do you reconcile the conflict between having disease-specific
programmes and at the same shoring up the health worker capacity
in developing countries?
Dr Lazarri: Thank you, Lord Desai, this is a
very important question. We try to reconcile that by trying to
do both because one is linked to the other. Vertical programmes
are not external to the health system, they are part of the health
system. The Global Fund was based in the Framework Document from
the beginning to provide resources to achieve results for the
three diseases but in ways to strengthen the system. What we are
trying to achieve is this diagonal approach; it is not vertical,
it is not horizontal; it achieves results for the three diseases,
but at the same time it reinforces and strengthens the system,
or at least tries not to undermine and avoid some of the potential
risks or unintended consequences you have referred to. It is not
easy. The system would require a larger investment than the Global
Fund itself has. There are many systems which are terribly weak.
The weakness of the system is, in fact, often the main bottleneck,
the main problem, in achieving results for the three diseases.
It is in the interests of the Global Fund, in reaching our objectives,
to address this bottleneck. You referred to human resources, which
is probably the largest, the most difficult one to address. There
are very few qualified health workers in many poor countries and
those who are good and qualified often migrate to better places,
including the UK, and it is difficult to replace or keep them
there. Quite a large amount of resources from the Global Fund
goes into training or providing, where it is feasible and in line
with national policies, incentives, benefits or whatever way a
country can design to try to retain their health workers, to better
qualify them and ensure they are there to do the job. That is
not something we can do alone, but it is something we have tried
very hard to address. You might be aware that recently, after
a long discussion at Board level, the Fund has agreed to a new
approach to health system strengthening that allows a country
to apply not just for health system strengthening activity as
a separate component—it is still an integral component of
the diseases that we are addressing—but they can come with
more ambitious and more focused system-strengthening proposals
that try to address these bottlenecks where they are identified.
The new approach allows countries to make ambitious proposals
that will not undermine the disease support; they will be addressed,
evaluated and approved separately from the disease component.
We hope that this will bring more proposals that include a greater
element of health system strengthening, including human resource
development, and in that way we will accelerate both the fight
against the disease and improve the overall health system in the
country.
Ms Stewart: If I may add, perhaps, some examples
of how that can work in a country. In Ethiopia, for example, part
of the AIDS funding that goes to that country is for the support
of the health extension worker programme, which is trying to reach
out into rural areas and really extend the reach of primarily
very first-line interventions, getting people to get tested and
so on. When they discussed that at the country level, they realised
it was impossible to do that only for AIDS because there was nobody
dealing with anything else. So the health extension worker now
does all sorts of primary healthcare interventions. I have seen
them in very rural areas giving vaccinations, et cetera, and they
also discuss how to do bednet distribution and encourage people
to be tested, about safe sex, distribute condoms and so on. In
many ways what we are trying to do is fund additional resources
that will be there for all sorts of health interventions, not
just for AIDS. Part of that is also the whole task-shifting discussion,
and these extension workers are sometimes doing the work of nurses
and other healthcare professionals who are in short supply and
where we could not get the coverage that we now have with those
extension workers if we waited for all the nurses to be trained.
We are trying to support that whole approach of broadening the
base. Similarly, in many of the countries, especially in southern
Africa, it is the health workers themselves who are most affected
by AIDS, TB and Malaria in our case, but primarily AIDS. Treatment
for AIDS is significantly benefiting the health service, and particularly
health workers because they are the first to be treated. In Malawi,
we have seen a significant increase in capacity within healthcare
workers simply because they are staying alive, which is obviously
the basic point. Also, in places like Zambia and Rwanda, where
antiretroviral therapy programmes are quite well-advanced, we
are seeing a reduction in the use of beds and so on in hospitals,
freeing up resources throughout the health system to treat other
diseases, whereas normally those hospitals are full of people
dying of AIDS. There are direct effects and, as Stefano was saying,
there are knock-on effects within the health system.
Q621 Lord Desai:
I just want to add the frivolous comment that earlier today we
heard the term "diagonal", not vertical and not horizontal.
It is like Pythagoras's theorem that the diagonal is more important
than the two sides. That is an interesting concept of having both
vertical and horizontal, so there is complementarity between those
two things.
Dr Lazarri: If I may, what you want to avoid
are the two extremes, programmes which are too vertical, too focused,
that are not sustainable in the long-term or very hard to sustain,
and we have had plenty of experience of those, as well as programmes
that are so broad, but lacking focus and concrete results, that
become difficult to sustain in the sense that you do not get the
required investment. The attempt to make it diagonal and make
the best use of the resources for the disease to strengthen the
system and making strengthening the system contributing to the
fight against the disease is the concept. Of course, it is an
image but it does provide an idea.
Q622 Baroness Whitaker:
Do not your private donors particularly want to have something
that is narrowly focused so there is a very measurable outcome?
Is that a tendency you have to educate people out of?
Ms Stewart: Yes and no. What we are experiencing
with the private donors is that we have been able to isolate stories
that we can tell, because we had no earmarking for our public
or private. What we do with our private funding is that sometimes
for their purposes they need to concentrate on a particular cause,
because the whole way in which fund-raising works is completely
different for public and private. For example, with the Red Campaign
they are focusing on AIDS in Africa and they tell stories to their
big consumers who are buying Red products about AIDS in Africa,
but we do not channel that funding directly in any way. They use
those particular stories, children on ARVs in Rwanda and so on,
because it is helpful for them to tell their stories, but it is
also important that they are in this bigger context of other things
that are going on; and, when they do their visits with the Red
advocates, they go and see the full programme. The extent to which
consumers especially are quite willing to process quite complex
development issues has been interesting and it is not just the
"keep one child alive for a year" kind of concept that
is possible not with quite a sophisticated set of consumers. They
are aware that there are much broader situations in the country
that have to be addressed. So far it has not been a huge challenge
for us in that way.
Q623 Chairman:
Dr Lazarri, you said the trick is to avoid the two extremes, the
extreme vertical and extreme horizontal. Whether or not you name
names, can you think of examples where there are these extremes
that are not going to continue to function? Are there examples
like that that trouble you?
Dr Lazarri: We have some examples of successful
vertical programmes. The best one is smallpox eradication. Eradication
programmes are very amenable to verticality because they are focused,
they have a limited time, they want to eliminate the problem so
you do not deal with it any more, and that is a good example.
There have been other examples where similar attempts have been
made that were not based on strong systems. Malaria eradication
is a good example. You cannot verticalise Malaria because it is
everywhere, transmission is broad because there is a vector, so
you really have to work in a more horizontal way to be able to
address that problem.
Q624 Chairman:
But overall at the present time you are not acutely concerned
that there is too much focus on either the vertical or the horizontal
by too many organisations?
Dr Lazarri: I think organisations are converging
anyway. It comes out of the opportunity of saying there are large
new resources for health driven mainly by disease programmes or
immunisation for polio or others and we should try to make the
best use of these resources and use them in a way that does not
just address the specific disease but has additional positive
spins on the system and develops the overall system. As I said,
there is a second reason why they are converging and that is that,
if you do not address the basic system weaknesses, you cannot
achieve the objectives of the disease programmes or you cannot
sustain them in the long-term. If the health workers are not there
and the infrastructure is not there, you will not be able to achieve
this. There is a win-win situation in becoming diagonal and seeing
how best you can merge these. I would not wish to say everybody
is on line with the diagonal approaches, there are still differences,
but the debate is on and I think the positions are converging
on that, and that is a positive.
Q625 Lord Avebury:
To pursue this analogy, I am wondering how you draw this hypotenuse
if you have to have this balance between the vertical and the
horizontal. You have already told us that you have a new approach,
which I take to mean your Framework Document, which I understand
does include allowing you to fund strengthening health systems.
But your answer just now seemed to imply that was so only when
the strengthening of health systems was directly related to the
main objectives of the Global Fund. I take it, for example, you
would fund sexual and reproductive health where you want to achieve
the twin objectives of reducing AIDS but at the same time improving
general health of the population, as in the case of Malawi for
instance. My first question is how you do decide what the balance
is between the two sides of the triangle in terms of your overall
budget. Do you decide that by means of a financial mechanism?
Or is there a set of criteria which you apply to all proposals
whether they are concentrated on specific diseases or on the strengthening
of the general health systems? Do they all go into the pot and,
as it were, the proportion comes out at the end of the day according
to the choices that you have made individually in each case?
Ms Stewart: Firstly, the important aspect is
that we do not decide centrally any of those things. Because we
are a country-driven process, we very much rely on the country's
national strategy and what they decide to apply for funding to
the Global Fund for, so there is no central management of that.
There are two important points. Firstly, we do not see ourselves
as isolated. We are not assuming that we are the only funder,
as you know it is a crowded landscape. We rely very much on our
Partners to fund supporting interventions, particularly around
health systems. GAVI, for example, has a whole health systems
component that they are currently funding. We are trying very
hard not to overlap, which is one of the reasons why we are focusing
very much on health system strengthening directly related to TB,
AIDS and Malaria outcomes. The other important factor is, of course,
that at the country level they need to decide on what the national
strategy is and what other funders are funding for them. In the
context of the horizontal-versus-vertical debate, I was going
to mention a conversation we are in with the European Union about
direct budget support and vertical programming. They are doing
a lot of budget support and giving a small amount to us for our
vertical programme. We see those things as complementary. A lot
of that funding has to go into the country to support these other
things and our funding will fund a specific aspect of that. We
rely on the country actors and the Partnership at the country
level to decide who might fund which piece and which is the piece
that they apply to the Global Fund for funding. You might want
to explain more about how that works.
Dr Lazarri: The distribution of the Global Fund
portfolio, whether it is across the diseases or by intervention
or geographical areas, is really decided by a process that starts
with a needs assessment at the country level, where the countries
themselves, through the Country Coordinating Mechanisms, based
on the epidemiological situation, on their understanding and their
resources, identify their programmatic and financial gaps. That
is the first part. We try to make it in as transparent and open
a way as possible. The Country Coordinating Mechanism then comes
up with a proposal, which is what they agree is their priority
for funding. That is the first thing that drives what we support
in countries.
Q626 Lord Avebury:
Whose Country Coordinating Mechanism? Is that yours? Or is it
the property of the country?
Ms Stewart: It is the country's.
Q627 Lord Avebury:
It belongs to the state?
Ms Stewart: Not the State, the Partners in the
country.
Q628 Lord Jay of Ewelme:
Who puts it together?
Ms Stewart: It could be convened by the government,
it often is, but often by the National AIDS Council, which is
often a partnership in-country between civil society, government
and other actors. In some countries they were first initiated
by the World Health Organisation and UNAIDS. UNAIDS, in fact,
supported the establishment of many of the Country Coordinating
Mechanisms. Increasingly, that is supposed to be part of UNAIDSs'
"Three Ones" concept, so one coordinating body for AIDS,
and in many countries that acts as a coordinating body for AIDS,
TB and Malaria, and sometimes other things. Wherever there are
players that go beyond government, and it is important that it
is beyond government, especially for HIV/AIDS, the Coordinating
Mechanism then takes all of those stakeholders at the country
level and they discuss what the priorities will be. It is very
much a joint process. Yes, often it is chaired by the State, the
Minister of Health, or in some cases the Deputy President. It
is often quite a high level organisation but it is not owned by
the State and it is certainly not supposed to be, it is supposed
to be a partnership. Many donors are on those Country Coordinating
Mechanisms. There is the voice of all the players.
Dr Lazarri: It includes donors, representatives
of technical agencies present in the country, and definitely should
include representatives of civil society, the non-government sector,
and representatives of the people living with the disease. We
try to have around the table all the key stakeholders involved
in or affected by addressing the disease. They are the ones who
in a sense are giving the first cut to the portfolio and the Fund.
The second one is done by our independent Technical Review Panel
that looks at the proposals and assesses them based on the soundness
of approach—is it technically sound? Does it have all the
elements we would like to see in a good technical proposal eg
feasibility? Do we see they have all the conditions to achieve
the results that they have indicated? And the potential for impact
and sustainability? These are the main criteria that the Technical
Review Panel, independently from the Secretariat, looks at and
they make a recommendation to the Board for the funding decision.
That is how it is shaped. In a sense, in that way the Fund does
not have its own priorities beyond the collective priorities of
our Partners in the country. That is the best way I can describe
it.
Q629 Baroness Whitaker:
When you say potential for impact, do you mean impact on the diseases
concerned? This is measured in a particular way, I suppose.
Dr Lazarri: Yes. It is measured overall by ten
core indicators of the impact of Global Fund resources which we
monitor for all countries. Each individual proposal has its own
indicators of performance, achievement and targets, which are
defined and set by the country themselves. We negotiate how that
is measured. Disbursement is based on achievement of results against
those agreed targets.
Q630 Lord Avebury:
Can I ask you specifically, I did mention it en passant,
about sexual and reproductive health. Are you aware of the campaign
for universal access to reproductive health being waged by Countdown
2015 Europe?
Dr Lazarri: Yes.
Lord Avebury: Does that have any impact
on the applications that are coming to you from Country Coordinating
Mechanisms? And can we be assured that there is not any political
inhibition on Country Coordinating Mechanisms applying for grants
in the field of SRH?
Q631 Chairman:
I like the idea that there will not be any political considerations,
but you had better give your answer.
Ms Stewart: I am project managing our Gender
Strategy at the moment, so it has been a big push over the last
year, firstly to get our strategic position publicised and in
place—and we are still working on that—and also to
push for this round for programmes that generally benefit particularly
women and girls but more gender specific and appropriate programming,
and in the case of AIDS, sexual and reproductive health rights.
What we are hoping for with the advocacy around the gender issue,
plus the new arrangements that are in place for health system
strengthening, is the combination of those two things will produce
a lot of integrated sexual and reproductive health programmes.
That is what we are hoping. Certainly we know there are obstacles
at the country level, but by integrating more of these statements
directly into our guidance to say, "We are expecting you
to look at X, Y and Z issues. We are expecting to receive programmes
that address sexual and reproductive health", we are hoping
that those obstacles will be overcome. To be specific, for example,
there is hesitancy at the country level, particularly on behalf
of the government, to apply for those things because they are
not sure that they would be funded, they are not sure they would
be perceived as being appropriate. So we have made sure those
questions are answered in the guidelines this time and no-one
can say we are not accepting proposals of that nature. Obviously
they have to be technically sound. The Technical Review Panel
will look at them and make sure that they are technically sound.
It has been challenging to integrate sexual and reproductive health
and HIV/AIDS programming, it has not always been successful. We
have had technical problems with previous proposals that have
come to us. We are optimistic because there has been a huge push
of technical assistance in this period. Stefano has been working
very hard with the World Health Organisation, UNAIDS and many
of our civil society partners and lots of coalitions and mobilisation
networks around the issue. We are hoping that Round 8 will bring
results on that. At the global level there is no political obstacle
to that. We have never had a technically sound proposal that has
been recommended to the Board that has been refused—never.
Q632 Lord Avebury:
Are you hinting that many Country Coordinating Mechanisms need
technical help in formulating SRH proposals? How would that be
accomplished? Are you able to go a stage earlier and help the
Country Coordinating Mechanisms to formulate applications?
Ms Stewart: We would see that as a conflict
of interest. We would not think it would be appropriate for us
to fund the country to produce the proposal that comes to us,
but that is a huge challenge in our model.
Q633 Lord Avebury:
Is it a gap?
Ms Stewart: Is it a gap? Stefano, you work on
that all the time.
Dr Lazarri: My colleagues at the World Health
Organisation would say that it is a gap, because they have not
been provided with the financial resources to be able to play
a technical advisory role in the development of the proposal.
It is an unfunded mandate, it comes on top of their responsibilities,
but it is their responsibility to help countries develop policy
and develop proposals. It is definitely part of their responsibility.
Q634 Lord Howarth of Newport:
We would be grateful to have your take on the World Health Organisation.
You just now pointed to a problem that changes in the international
scene have posed for them. The world has been changing a lot and
your arrival on the scene in 2002, bursting on the scene as a
very important and very big player, is among those significant
changes. Do you feel that the WHO is reacting constructively and
appropriately to this changing international geography and architecture,
of healthcare and health policy? How are they as collaborators,
as partners? I know they are on your Board, they are a Board and
Development Partner. But can you tell us more about how you work
with them, the complementarity?
Dr Lazarri: I need to declare a conflict of
interest because, in fact, I am WHO staff seconded to the Global
Fund.
Ms Stewart: Great collaboration!
Q635 Lord Howarth of Newport:
Clearly a very beautiful relationship!
Dr Lazarri: It is an example of how the collaboration
is increasingly positive in defining the roles and collaborating
together. There has been lots of development that has resulted,
for example, in much higher approval of the Malaria grants and
better performance of the role of the grant portfolio. I will
say that is definitely increasing and I see that in two ways.
We rely on the WHO, UNAIDS and other technical partners for the
policy/strategy guidance, where the resources should go and what
are the most appropriate interventions, what provides the best
results in different conditions—because the Fund is not
a technical agency, it cannot decide on that. It cannot even decide
on the priorities. We rely on their work in providing the global
guidance, and this is through UNAIDS, the Stop TB Partnership,
the Roll Back Malaria Partnership and the work of the technical
departments of WHO. We are increasingly collaborating with the
health system and services cluster and with the making-pregnancy-safer
reproductive health groups in aligning all these policies.
Q636 Lord Howarth of Newport:
In your perception, your WHO colleagues are indeed providing the
kind of strategic vision and context that you need in order to
know how to take your place most usefully in the array of efforts
that are being made?
Dr Lazarri: I really think they are doing their
best under some of the limitations that WHO has. I could put my
WHO hat on and answer that, but as the Global Fund I do not think
we can comment on that. It is improving and we are seeing the
results of that. The second part, which is what may be linked
to the availability of resources in WHO, is the technical assistance
at country level. That has also improved greatly, both in the
development of the proposals, where there are training workshops
organised with countries to explain the forms and guidelines,
in which the Global Fund also participates in part, not on the
technical content but how to fill in the form and what are the
new developments parts. We do that in collaboration and it has
become a routine activity when the grants are launched. We have
just finished a series of these workshops around the world. Then
there is also providing consultants to countries to write the
specific proposal and this is something that, as the Global Fund,
we do not intervene in. Later on there is implementation, which
is also important because, once the proposal is approved, you
have to negotiate a grant and that requires definitional and technical
elements. It is important the performance of the grant is up to
speed and that requires technical assistance. That is where WHO
and other agencies have made an effort, but it does not cover
all the needs because of a lack of resources. It depends a lot
on the Regional Offices and what their attitude is. This could
cause some regions to be much more proactive in working with the
countries and others to sit back and just respond to requests.
We can see these differences across some regions. There is still
progress that can be made.
Ms Stewart: An important element of our relationship
with WHO has been our hosting agreement and, from the Global Fund's
perspective, that has been a challenge, certainly in the early
days when we were both hosted by WHO administratively but they
were also a collaborating technical partner. The fact that we
are moving out of that hosting arrangement at the end of this
year and will become fully independent will assist in the clarification
of roles and responsibilities and improve our technical relationship.
As Stefano said, it is going in the right direction, it is incredibly
positive, and certainly on things like preparing for the rounds
the collaboration is enormous, daily and invaluable. Once the
administrative arrangements are clarified, it will take the pressure
off some of that relationship in a way. I do agree that there
is definitely a difference between our global collaboration and
our reliance on them for even coming in and briefing our Technical
Review Panel, keeping them up to speed with all the latest technical
developments and so on, and collaboration at the local country
level, where it is totally dependent on individuals and particular
regions for what actually happens.
Q637 Lord Howarth of Newport:
If they do not have enough resources to do what you would hope
they could do, should do, in future funding rounds, would it be
preferable that they should receive more resources and you slightly
less?
Dr Lazarri: You are the fund-raiser!
Q638 Chairman:
You can do a Yes or No answer if you like.
Ms Stewart: Our position has always been that
it is much more important to increase the whole pie than to play
one group off against another: we do not see that as helpful.
Our money is channelled entirely to countries for countries to
spend, our overheads are incredibly low compared to anyone you
want to compare us to. The funding that is being provided to the
Global Fund is going directly for implementation. WHO's challenge,
of course, is that they are a normative agency, not an implementer,
so it is very hard for them to mobilise in the same way that we
can. There is also some debate about the extent to which technical
assistance should be provided directly from WHO itself. They are
setting the norms, the standards, the appropriate interventions,
and educating people on what is appropriate in terms of response.
Should they be going out there and funding proposal preparation
and so on? I think that is a conversation that they also have
to have. I do not think there is even agreement everywhere in
WHO about exactly how far they should be going down that very
hands-on route. Certainly there needs to be more support at the
country level all round. Particularly on the work around gender
and sexual and reproductive health, a large part of that is being
done by civil society, foundations and other funders, not necessarily
WHO. WHO is setting very important guidelines, and so is UNAIDS,
in that area. There is no other comparable agency who can do that,
that is absolutely what they have to do. Whether they need to
be down there helping the countries to interpret that into a viable
proposal for the Global Fund is maybe a complex issue.
Q639 Chairman:
I am interested in these two hats that you wear, Dr Lazarri. If
you take Lord Avebury's question on sexual and reproductive health,
could you go into a situation and put on your World Health Organisation
hat and say, "Actually we cannot fund that whatever, but
we, as the Global Fund, can help you set up the structure that
would enable it to be funded"? Does that happen?
Dr Lazarri: The Global Fund cannot support WHO
directly, it is not part of our mandate. The resources of the
Global Fund go to country programmes for implementation. What
we can do, and definitely do, is collaborate with them, so that
in a sense they can mobilise their resources where needed. It
is not only WHO. At least for the three diseases we are talking
of, a broad range of partners rotates around a partnership for
Stop TB, Roll Back Malaria and around UNAIDS and their co-sponsors.
It is not just the World Health Organisation that can provide
and does provide support. When it comes to reproductive health
or health systems, we have less developed partnerships globally.
The number of partners that it can support is limited, even the
number of technical experts available is limited. They start from
a more difficult position when requested to provide support to
countries for proposal development. I would see a need for investment
there definitely. I do not know what hat I am wearing, but maybe
with both hats I could say that, if we want them to be able to
respond to these requests from countries in areas which are outside
HIV, TB and Malaria, they would require additional resources.
Also, it is better co-ordination, recruiting partners who can
fill in the gaps and provide support, and there is quite a number.
It is moving. We have started to see a movement in reproductive
health and in health systems and I think it will expand even more.
Maybe I should mention that, if this is true for proposal development
where we see a conflict of interest, when it comes to implementation
of the grants, then the Global Fund can provide support to technical
assistance, it can and it is included in the proposal. I cannot
remember the figure exactly—I can provide it to you—but
we tracked this for Round 7 and I think we had four or five per
cent of the resources that were for technical assistance. There
is funding available within the grants that can be used to provide
technical assistance and implementation, including, if countries
so wish, from WHO, so that is an area where the Fund can indirectly
support international organisations through the grant and the
country.
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