Tropical Health Matters

the Nigerian press has expressed worry that, “the country slipped from its previous position of the 112th of the most corrupt nations to 130th, out of the 180 countries surveyed. Rather than receding, as the (Transparency International) report seems to suggest, the reality is that corruption is becoming more pervasive in the country.”

Transparency International’s Corruption Perceptions Index (CPI) “measures the perceived level of public-sector corruption in 180 countries and territories around the world. The CPI is a “survey of surveys”, based on 13 different expert and business surveys.” In the Africa section of map above the darker the shade of blue, the higher the perceived level of public sector corruption.

Positioned next to the CPI map is the Malaria Atlas Project’s map of P. falciparum distribution in Africa. Here darker orange implies a higher burden of disease. The juxtaposition of the two maps does not mean that malaria causes corruption or that corruption causes malaria. This positioning is intended to make us think about the challenges of controlling this deadly disease in an environment where program management may be threatened by corruption.

One of the more infamous cases concerned Global Fund projects in Uganda where “allegations of mismanagement of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria … led to the Global Fund’s decision to suspend grant funding in Uganda in August (2005).”  Earlier this year grant funding was suspended in Mauritania due to confirmed fraudulent practices.

Even when ultimately no evidence of corruption is found, weak management processes, especially in the area of procurement and supply can lead people to suspect corruption.

As early as 2004 the Global Fund addressed processes that could ‘safeguard’ grants and ensure appropriate, transparent and accountable recipients could be designated. Examples of situations where this would be needed “could include significant concerns about governance; the lack of a transparent process for identifying a broad range of implementing partners; major concerns about corruption; or a widespread lack of public accountability.”

The current and ongoing push to achieve and maintain universal coverage will be placing much strain on health and governance systems in endemic countries.  We hope partners will be vigilant to ensure that corruption and mismanagement do not derail the goal of eliminating malaria in each country.

… can buy a $35 million estate in Malibu, California, a fleet of luxury cars, speedboats and a private jet, according to the New York Times. What does it buy for the poor, malaria stricken people of Equatorial Guinea?

“… despite a federal law and a presidential proclamation that prohibit corrupt foreign officials and their families from receiving American visas,” The Times reports that the owner of this California wealth, Teodoro Nguema Obiang, the Forest and Agriculture Minister of Equatorial Guinea and the son of its president, is allowed to enter the US freely.

In the malaria world, Equatorial Guinea has been recently help up as an example of progress along the pathway to malaria elimination. On the third day of the recently concluded MIM 5th Pan-African Malaria Conference Equatorial Guinea, or more specifically its better endowed island half, Bioku featured as a case study in the plenary session.  According to TropIKA’s daily conference summary …

Bioko, off the coast of Equatorial Guinea, was the next case example, another “island laboratory” with important lessons for the mainland. Dr Immo Kleinschmidt discussed the first 5-year phase of the island’s malaria control project. There has been huge success in some places, he said, but others continue to struggle, and though Bioko is on the road to elimination, “it’s not going to be easy.”

Several other presentations featured the Bioku experience.These come on the heels of recently published articles in the American Journal of Tropical Medicine and Hygiene detailing results that “provide encouragement that the additional resources for combining IRS and LLIN are justified,” and that “Effective malaria control measures can dramatically increase child survival and play a key role in achieving millennium development goals.”

An accompanying editorial in AJTMH makes more clear than the articles that possible funding for the interventions studied may have come from Marathon Oil’s 2003 infusion of US$ 15.8 million to reduce malaria transmission on Bioko Island and possibly more recent Global Fund support to sustain intervention.

While government is said to be a partner in such enterprises, it would appear from the New York Times article that corrupt government officials alone could have eliminated malaria long ago on both Bioku and the mainland with money to spare for other African countries that lack the ability to siphon off oil profits for personal use.

The AJTMH editorial asks, as it must, whether the reported gains can be sustained.  Global Funds may or may not continue, but the writer hopes that corporate responsibility and its philanthropy will continue to maintain the scale-up of malaria interventions.  If those two sources fail, maybe the Minister of Forestry and Agriculture can sell his Malibu estate for the benefit of his country people.

Just last November IRIN/PlusNews published a list of countries who are “Falling foul of the Fund.” What distinguishes this ‘club’ of 10 countries on the list is poor performance that resulted in cancellation or suspension of their Global Fund grants.  For example, in Pakistan the, “Fund discontinued support for (its) malaria projects because of weak project implementation, slow procurement of health products, poor data quality, and slow spending of project funds.” Uganda was one of the worst case scenarios according to PlusNews:

In 2005, the Global Fund temporarily suspended all five of its grants after a review by PricewaterhouseCoopers of one of the grants revealed evidence of “serious mismanagement” by the Project Management Unit in the Ministry of Health. The grants were worth a total of $201 million over two years, of which $45.4 million had already been disbursed. The health minister and his two deputies lost their positions and are on trial with several other government officials for charges relating to the misuse of Global Fund money.

Now there are reports out of Lusaka, Zambia that the Ugandan ‘model’ may be repeated, but only to the tune of $2million. “The governments of the Netherlands and Sweden announced they had suspended aid after a whistleblower alerted Zambia’s Anti-Corruption Commission [ACC] to the embezzlement of over US$2 million from the health ministry by top government officials.”

In Zambia, like many malaria-endemic countries, “most of the national health budget is donor-funded.” The report highlights the suffering of people affected by the HIV, malaria and TB when the misbehavior of public officials threatens the funds that keep those suffering alive.

While this experience may feed into the recent debate on the value or danger of foreign aid, the reality is that the massive efforts to control major diseases requires support from the global community – support that recognizes our common humanity.  A positive example is Rwanda where the national health account shows that in 2006 donor support accountred for 53% of total health expenditure.  Rwanda has become the poster child for the benefits to malaria control and eventual elimination, but just a slight step to the dark side, as it were, could jeopardize all the gains in a minute.

Clearly if we want to eliminate malaria the solution is not to withdraw or withhold funds from endemic countries. The question is do we have accountable mechanisms for using the funds? Do we put all our funds in one basket, or do we spread them among public, private and civil society sectors?  Without viable answers to these questions, malaria will never be eliminated.

While Cheney and Obama are debating approaches to national security in the US, the international community is still debating whether development aid should continue or not.  In the latest salvo, Jeffrey Sachs wonders at the fact that critics of aid themselves have benefited from such aid … “I certainly don’t begrudge any of them the help that they got. Far from it. I believe in this kind of help. And I’d find Moyo’s views cruel and mistaken even she did not get the scholarships that have been reported … I begrudge them trying to pull up the ladder for those still left behind.”

According to the Zambian Economist “Dambisa (Moyo) is tired and frustrated by the aid apparatus that has not only come to “trap” poor and indebted African states but is, in her view, the root cause of poverty.”  It is unlikely though that the huge apparatus of international development aid is going to disappear at the wishes of doubters like Moyo.  But is aid doing what it is supposed to do without the unintended consequences critics note?

Moyo’s views do touch a chord.  A colleague from Africa wrote to me today, “I often think that countries like (mine) do not really deserve any aid in view of the magnitude of corruption among their leaders. I never read any good news about my country. It is one case (or another) of a leader carting billions of dollars away .”  We have certainly witnessed embezzlement of GFATM money, but should we throw up our hands and admit that aid is defeated?

In the case of malaria, progress seen in places like Rwanda, Zanzibar, and Ethiopia would not have been possible without GFATM, PMI and other aid programs.  One can still ask if such progress is sustainable.  Watching donor disease control efforts over the years – guinea worm, onchocerciasis – one feels some dis-ease about whether such programs, no matter how much they contribute to human development, are really wanted. What are national priorities – do governments tolerate big infusions of money for special projects simply because they are big?

Is this aid by fad, and can donor fatigue be prevented until the big diseases are eliminated? And does aid corrupt and large aid corrupt absolutely?  Does aid build systems or simply help with cash flow?  Where is there accountability – not just can recipients account to donors – but also can donors account to the people they are trying to serve?  Aid that does not enable a voice for people and communities is really nothing more than well intentioned cash flow.

It would be tempting during these economic hard times to let the aid naysayers win the day.  The challenge therefore is to build a system that not only uses aid in a way that helps people now but ultimately sets the stage for generating new local and appropriate resources that may one day replace that aid.

The Daily Nation in Nairobi calls the inability to trace missing money from the country’s Global Fund Grants the “Shame of reaping from the sick and dying.” Although Government had set up a task force three months ago, the current Public Health Minister, “pompously announced that no funds were misappropriated after all, despite her Medical Services counterpart Anyang’ Nyong’o’s and her own earlier admission that the money had been stolen. Perhaps in their preposterous belief that Kenyans are such a forgetful lot, the two ministers that owe Kenyans an explanation over the Global Fund’s saga have resumed business as usual.”

The article provides details on other money that has disappeared from government coffers:

• Sh19.3 million from the joint Kenya Medical Research Institute (KEMRI)/US Centres for Disease Control bank account in Kisumu
• Last month, Kemri’s entire pension fund amounting to Sh 537 million went missing

The ramifications of the Global Fund problem are starkly highlighted by the Nation – literally children dying from malaria and AIDS patients dying from tuberculosis and lack of food.

Not only was Kenya denied Round 8 funding from the Global Fund, but application for Round 9 funds was put on hold until the task force resolved the problems.  Apparently officials believe that the task force is no longer needed since the Minister “insisted the Government would apply (for Round 9), after all.”

The Global Fund and its contributors are persistent and will not be as ‘forgetful’ as Kenyan citizens are thought to be.  In fact advocacy from Kenyan citizens to save their own lives will probably go a long way to solve the problem, if they are not muzzled by the new media law or caught up in political uncertainties persisting after the last botched elections. Government’s openness and accountability, it seems, are actually preconditions for the health of its citizens.

The current global economic crisis has resulted in caution and worry for public health. The Global Fund Board at its 18th meeting decided that, “The Round 8 proposals to be approved for funding by the Board shall collectively be subject to a 10% adjustment (i.e. cut) for efficiency.”  While Global Fund money can help strengthen health systems, it is not meant to build systems or replace national financial commitment to health care.

What then happens when funds appropriated for health services do not reach the front line where primary care services, including malaria control, are delivered? Gauthier and Wane report on Chad that …

Although the regional administration is officially allocated 60% of the ministry’s non-wage recurrent expenditures, theshare of the resources that actually reach the regions is estimated to be only 18%. The health centres, which are the frontline providers and the entry point for the population, receive less than 1% of the ministry’s non-wage recurrent expenditures. Accounting for the endogeneity of the level of competition among health centres, the leakage of government resources has a significant and negative impact on the price mark-up that health centres charge patients for drugs. Furthermore, it is estimated that had public resources earmarked for frontline providers reached them in their entirety, the number of patients seeking primary health care in Chad would have more than doubled.

Gauthier and Wane surmise that donor support of health in Chad may actually contribute to the problem. Their study has “shown that current resource allocation seems to be linked to the discretion of regional and district administrators, and that international donor support introduces a strong crowding out effect, whereby health centres that received foreign assistance are less likely to be supported by higher administrative levels.”

Efforts had been made by the World Bank and other donors to ensure that Chad spent its burgeoning windfall of oil money on social services and poverty reduction, but the government managed to back out of its pledge. According to the New York Times, “Chad has been ranked with Bangladesh at the world’s two most corrupt countries by the corruption watchdog Transparency International. The hope that Chad would chart a more humane path fractured when its Parliament voted … to soften the oil revenue law, allowing the money to be diverted.”

Another World Bank study in Nigeria identified similar financial accountability problems with local government health funds. “Even when budget allocations were sufficient to cover estimated actual costs, the staff survey revealed non-payment of salaries for several months in the year before the survey. The paper argues that the pattern of evidence shows that non-payment of salaries cannot be explained by lack of resources available to local governments. The evidence therefore suggests that there is a general problem of accountability at the local government level in the use of public resources that are transferred from higher tiers of government.”

As seen in the picture, lack of accountability also means local government clinics are in disrepair, discouraging attendance by clients. The Nigerian study also laments that “local citizens may not be well informed” about these problems and are thus not disposed toward advocacy. Who then will be the advocates to prevent leakage?

Three years after “about $1.6 million of Global Fund money had been misappropriated or could not be accounted for” the authorities in Uganda may be about to take some action to resolve the case, ” according to the Global Fund Observer (GFO). A whistle blower had informed GFO back in 2005 about the missing and misappropriated money prompting the Global Fund not only to suspend Uganda’s (at the time) 5 grants, but also to create an independent Office of Inspector General. The GF allowed the Uganda grants to resume operation later in 2005 after management reorganization had taken place, but to date the prosecution of the guilty and the return of the money has lagged.

The GFO reported that, “Finally, in April, the Norwegian AIDS Ambassador, who represents Norway and several other European countries on the Global Fund board, wrote to the Global Fund’s Inspector General.” They made it clear that donors would not tolerate further delays in the prosecutions and return of funds. An official visit by the GF made this demand in person last month.

While testimony by 150 people about the case identified multiple ways that funds were spent lavishly or were diverted by the Ugandan authorities, the process also found that the Local Fund Agent (LFA), the supposed independent monitoring watchdog of the GF in each country, was asleep on the job. Such incidents undoubtedly have also led the GF to evaluate the LFA process and recommend improvements that combine both financial as well as technical monitoring in the future.

Donor attention may have led to Parliamentary action in Uganda. The Monitor reported that, “The coordinating agency of the Global Fund funding for HIV/Aids in the country has issued strict disbursement rules, banning politicians from taking part in the running of the funds. Speaking at Parliament on Wednesday, Dr Kihumuro Apuuli, who heads the Uganda Aids Commission, told Public Accounts Committee that under the new stringent guidelines, Global Fund (GF) cash will be given directly to ministries through accounting officers. ‘There is no politician who will touch this money,’ Dr Apuuli said. ‘Any form of [GF] funding will require a suitable work plan approved by the commission,’ he said.”

The Monitor offers a deeper reason for these problems when it reported Uganda’s status among the 20 weakest, most vulnerable states in the world. The Fund for Peace ranks Uganda the 15th most vulnerable of 177 countries in 2007 (see map). The Monitor thinks that one of the major reasons is Factor Number 7, “Criminalization and/or Delegitimization of the State.” Three components of this factor mirror the problems experienced with the Global Fund in Uganda:

• Massive and endemic corruption or profiteering by ruling elites
• Resistance of ruling elites to transparency, accountability and political representation
• Widespread loss of popular confidence in state institutions and processes

Ultimately it is a testament to GFATM processes that more of such incidents of thievery have not occurred.  Ironically in other cases of threats to grant suspension the cause is more often NOT spending the money on time and thus, not achieving results. In either case, accountability is needed. The Monitor again opines that donors not only should demand accountability for their own funds, but also for all public monies.  They fear that ‘creative bookkeeping’ may be used in Uganda to make it appear that the stolen cash has been recovered, while in the process further impoverishing public finances.

Two global financial issues appeared online today – accounting for Global Fund grants and reduced IMF loans. What do they mean for malaria control?

Three years ago Global Fund grants in Uganda were suspended basically because money was stolen. After highly visible firings of top officials and efforts to audit the program and improve accounting, the grants were allowed to continue and new grants have been awarded. A recent visit by a Global Fund official reported in the Monitor reminded the Ugandans that the US$ 1.6 million still missing has not been returned.

After sacking of 3 top officials and transferring another, some funds were returned, but no further action has been taken. 24 priority cases are yet to be prosecuted, but 373 cases should be investigated according to the Monitor. In short, the people who perpetrated the theft and mismanagement are still at large and presumably still involved in the management of the Global Fund-supported programs. The excuse is financial – no funds to investigate the cases! Will this unresolved problem jeopardize Uganda’s international malaria funding again?

While many countries are expanding their malaria efforts using external funding, the question arises concerning long term ability of countries to maintain programs. Overall IMF loans have dropped from US$ 117 billion in 2003 to only US$ 16 billion in 2007. The Washington Post article identified malaria endemic countries like Ghana that “had joined a long list of developing countries in Africa and beyond enjoying record periods of growth, with the robust economy leaving it no longer in need of more IMF cash.” Ghana is even issuing its own bonds to improve infrastructure. Specifically the Post says that, “The economy here turned as hot as the local pepper soup earlier in the decade, with soaring global demand for the nation’s riches — gold, cocoa and bauxite — sparking a rush to modernize Ghana’s decaying roads, rails and power grid.”

Whether Ghana will also turn some of its profits to disease control now or in the future remains to be seen, but these experiences point out the importance of promoting equitable global trade as a long term solution to helping countries fund their disease control efforts and wean countries from foreign assistance that appears too sweet and easy for some government officials to avoid tasting.

The Sunday Times has reported that, “The world’s largest Aids fund has been the victim of a multi-million-pound fraud involving its programme to help chronically ill children in Africa.” Full details have not been released but, “Whitehall sources said that the concerns related to a Global Fund contract given by the United Nations Development Programme (UNDP) to a firm in Denmark. The firm is said to have received help from a British aid consultancy, which has led to suspicions of kickbacks.”

Allegations of Global Fund ‘misdirection’ or ‘loss’ have occurred at the country level. For example, a series of articles in Kenyan newspapers addressed problems of supposed financial impropriety. Accusations of fraud were raised by one government agency against another (The Nation, 26 June 2003). Another article described concerns over lack of timely releasing of and reporting on funds (The East African Standard, 17 March 2006). The issue of lack of transparency and accountability were mentioned when there were drug shortages (The East African Standard, 24 July 2006).

In neighboring Uganda the New Vision reported on 31 December 2006 in a year-end report that, “Mismanagement of the Global Fund dominated the media throughout the year.” Former Cabinet Ministers were implicated in fraud and demands for refunds were made.

In no way should these allegations be taken lightly, but one explanation for the inability in come countries to account may be systemic. Traditionally in most health ministries and agencies program reporting and financial reporting are separate processes serving separate masters. The Global Fund, in contrast, requires that program and financial reporting be linked in order to guarantee that performance based funding (PBF) can occur. As a guiding principle the Global Fund aims to “Focus on performance by linking resources to the achievement of clear, measurable and sustainable results.” Countries often learned about PBF through trial and error since the Global Fund does not provide technical assistance, either management or programmatic, to countries. Not surprisingly during the start-up period, and even into the fourth or fifth year of Global Fund experience, some countries were still trying to link the programmatic and financial channels in reporting by their principal and sub-recipients.

A lack of link between financial and programmatic aspects of projects could as easily imply poor accounting practices as it could embezzlement. Holding of judgment until evidence was in was necessary at the country level, and consequently few grants have been suspended or canceled to date.

Back to what The Sunday Times reported – what appears to have happened is on a grander scale and completely inexcusable. Obviously the Global Fund needs to focus not just on country performance, but also on all the international systems that support procurement and assistance for those countries. There are big fish to catch.