Category Archives: Funding

Death by Sequestration

Across the board cuts in US funding for almost everything government does (except the salaries of members of Congress!), will have effects on people’s lives. Damage from sequestration is reported daily. Even civil rights are threatened as reported in the Washington Post in a story that highlights the plight of poor people who must remain jailed because funds for public defenders have been cut and there are not enough lawyers to ensure a speedy trial.

amfAR, The Foundation for AIDS Research, has been tracking the potential effects of the sequester on global health programs of the US Government. amfAR has made estimates based Congress’ action in January 2013, and reported that, “The Office of Management and Budget (OMB) has calculated that, as of March 1, 2013, funding for non-defense discretionary programs must be cut across the board by 5.0 percent.1  As we found in our earlier calculations, applying sequestration cuts to US government global health programming will have minimal impact on deficit reduction, but will be devastating to the lives of many thousands of people globally.”

sequestration-infographic_031113-malaria-part-sm.pngHere are the specifics on malaria programs:

  • 1.16 million fewer insecticide-treated mosquito nets will be procured …
  • leading to over 3,000 deaths due to malaria
  • 1.9 million fewer people will receive treatment

InterAction and Global Communities have produced an informational graphic that summarizes the impact on disease control, nutrition and education (see malaria section to right). This comes as part of a general leveling and possible downturn in malaria funding over the past few years. It will be hard to sustain the scale-up in malaria interventions that has been achieved since the United Nations called for universal coverage in 2009.

Most of the decision makers who vote on funds to curb global disease scourges will not likely ever see a case of malaria, much less experience one.  Hopefully this does not mean that they will be immune to advocacy to prevent needless deaths from malaria and other causes of maternal and child mortality.

Towards a Malaria-Free Kenya

Elizabeth Kubo has written this guest blog posting that originally appeared in SBFPHC Policy and Advocacy.

Malaria is a leading cause of morbidity and mortality in many developing countries, where children and pregnant women are the most vulnerable groups. In Kenya, the disease is responsible for 34,000 under five child deaths annually. About 70% of Kenya’s total population is at risk for malaria.

itn-use.jpgWith funding predominantly from international donors and development partners, the country has adopted and implemented multiple malaria control strategies, resulting in a remarkable decline in the national all-cause under 5 mortality. Despite the gains, a slight downward trend was noted in the proportion of households with at least one insecticide treated net (ITN), the proportion of children under five years old who slept under an ITN, and the proportion of pregnant women who slept under an ITN between 2008 and 2010.

The Global Fund for AIDS, Tuberculosis and Malaria, the Department for International Development (DfID), and the US President’s Malaria Initiative have confirmed funding for the 2013 implementation period, but this falls short of the expected need. Despite repeatedly reiterating its commitment to the fight against malaria, the Kenyan government has previously played a minor role in financing the control efforts.

There is an urgent need to intensify scale-up of targeted interventions in order to reverse the downward trend and attain universal targets. It is possible to close the funding gap through greater in-country resource mobilization. Government commitment to malaria control needs to be reflected in ministry of health budgetary allocations. Civil society organizations also have a role to play. It is possible to have a malaria free Kenya.

Fakes and Fraud: another threat to malaria funds

While some countries are being praised this week for their progress in controlling malaria, Uganda seems to be suffering from a double knock out punch when it comes to malaria financing. Challenges have appeared in both the private and public sectors.

In the most recent scorecard from the African Leaders Malaria Alliance (ALMA) scored poorly in terms of long lasting insecticide treated net distribution and low on the measure of government financial support for the health sector.

herbshop2a-sm.jpgThe private sector challenge has come in the form of fake medicines in local shops. This comes in the form of a threat to individuals and families who spend their hard earned cash, that is out-of-pocket expenditure (OOP) of malaria medicines that at best inappropriate and at worse are devoid of active ingredients, increasing the likelihood that the sick person will develop severe disease and maybe die.

Specifically the Washington Post reported that an indigenous medical practitioner “in Kampala, says he has seen a big increase in business as patients turned off by the prospect of dangerous fake drugs seek relief from illness.” The article explains that although “Officials and international aid agencies have long encouraged the sick to place their trust in modern medicine. But fake pharmaceuticals believed to have come from Asia have flooded” African Markets including Uganda.

The irony is that Uganda is part of the testing of the Affordable Medicines Facility malaria (AMFm) project that was supposed to drive out fake and inappropriate medicines by making low cost (subsidized) quality antimalarials available in both public and private sectors. While Uganda witnessed an increase in market share of the green-leaf branded quality assured artemisinin-based combination therapy drugs, it did not achieve other benchmarks such as supportive behavior change communication and low cost targets (mark-up averaged 133% – highest among the 8 pilots).

The second threat comes from extensive embezzlement by national malaria program staff.  Earlier this month Uganda was in the news for returning 4 million Euro of misappropriated funds to the Irish Government.

Then an ongoing investigation into embezzlement came to light a few days ago. The Observer Newspaper as shared on reported that …

“An investigation into the financial practices of officials running the ministry of Health’s Malaria Control programme (MCP) shows they forged almost everything from workshops, car hires, allowances and fuel expenses. The investigation has now shifted its focus to the extent of the forgery and theft by officials implicated in the loss of nearly Shs 78bn (US $29m). The shift in the focus of the inquiry follows a review of stacks of documents provided by three suspects involved in the MCP scandal. Police confirm that the documents show the extent of the forgery by some officials involved in the anti-malaria campaign.”

In these times when it is difficult to increase health development spending for malaria both domestically and from international donors, all efforts are needed to ensure that waste and fraud are eliminated.

Have we reached a funding plateau for malaria?

As all eyes are on the Global Fund to Fight AIDS, TB and Malaria with its launching of the new funding mechanism in February 2013, but we have been cautioned to curb our enthusiasm.

Karanja Kinyanjui in Aidspan’s Global Fund Observer explained that “While funding for all health sub-sectors grew over the 2002 to 2010 period, funding for HIV/AIDS, malaria, and TB increased at faster rates than other sub-sectors such as family planning, nutrition, workforce/management and other infectious diseases,” the growth spurt has leveled off. Readers were asked to see the new Kaiser Family Foundation report on the funding situation.

For malaria we are likely to be plateauing at levels that are only half of what is needed annually to move countries into the pre-elimination phase. The Kaiser Report specifically concludes that …

“While health grew as a share of overall ODA between 2002 and 2010, reflecting its priority among donors, year-to-year increases peaked in 2007 and have declined in each subsequent year. Combined with the OECD’s announcement that ODA in 2011 declined in real terms after more than a decade of steady increases and preliminary estimates that ODA (overseas development aid) is not expected to increase significantly in the coming years, caution about future donor assistance for health may be warranted”

kaiser-oda-for-health-2002-10-sm.jpgODA Health funding did grow from $4.4 billion to $18.4 billion between 2002 and 2010. Even under this increase, malaria funding did not meet needs. Malaria was a negligible component in 2002, and reached $1.6 billion, but this along with aid for nutrition, reproductive health, basic health services and others was dwarfed by HIV/AIDS funding at $7.4 billion for 2010.

In the past two years since the Global Fund Round 11 was cancelled there has been “a significant impact on programmes to fight AIDS, TB and malaria including, in particular, programmes being implemented by civil society organisations (CSOs). Programme scale-up and even some essential life-saving interventions that were planned by countries were halted.”  The transitional funding mechanism allowed some countries to tread water, but the new start up in February will not hit the ground with funds for at least a year.

Other aid sources such as bilateral programs in the UK, USA and Germany and multilaterals like the World Bank and UNICEF are certainly key players in malaria program financial support, but their help can supplement the big source, Global Fund, not replace it. Bilateral programs in particular are hit by budget problems that yield at best no increase in ODA, if not cuts.

The Eurasian Harm Reduction Network describes the current funding situation succinctly – “Quitting while not ahead: The Global Fund’s retrenchment and the looming crisis for harm reduction …” The situation with CSOs shows their dependence on large donors, too – so we cannot find our way out by simply donating to charity no matter how many NGOs assure us our individual dollars will give someone a bednet.  Malaria elimination is a problem that requires going to scale by the whole global community.

Malaria Funding – advocacy and creativity needed

Is there a malaria lobby? Who advocates for more funds from donor countries and within endemic countries? The Roll Back Malaria Partnership has a Malaria Advocacy Working Group (MAWG) that has as one of its objectives, “to ensure the wide dissemination of accurate information on resource allocations to inform the malaria community of current status and improve accountability both by donors and implementers.”

The MAWG has drawn attention to the wide scope of efforts to enhance malaria funding to support the Global Malaria Action Plan.  In addition to the usual international donors and domestic/government support MAWG points out the need to consider innovative fund raising mechanisms such as UNITAID’s air ticket tax. There is also stress on cost efficiencies with existing funds such as …

  • More effective ways of procuring LLINs
  • Less overlap of LLIN and IRS programs, at least until benefits are proven
  • Rotation of insecticides used for IRS to delay resistance
  • Accelerated availability and appropriate use of RDTs
  • Better understanding of efficiencies of integrated health packages

illustrative-alma-scorecard-sm.jpgThe African Media and Malaria Research Network (AMMREN), was formed in November 2006. It has over 100 member journalists in 10 African countries, and is encouraging more journalists to become involved. One of AMMREN’s key Objectives is to advocate for implementation of international agreements on malaria signed by African leaders. Local advocacy becomes even more crucial with CCMs when it comes to future division of Global Fund support among the three diseases, and addition to boosting local counterpart funding.

Arsenio Manhice, an AMREN member and a reporter for the newspaper Notícias based in Maputo, Mozambique provides an example of this advocacy function. He reported on the lack of qualified human resources for malaria work and also spoke of the lack of infrastructure and logistics for indoor residual spraying. These logistical resources are the kind that need major national financial commitments for sustainability.

Both Ethiopia and the US Agency for International Development, according to VOA, are encouraging African countries to adopt a “scorecard that publicly collects and reports health data.” Such a scorecard would track 1) input indicators that relate to policy issues and availability of resources; 2) process indicators; and 3) impact and outcome indicators that outline the data results. This is an important tool for both accountability and advocacy.

A scorecard actually already exists and is maintained by the African Leaders Malaria Alliance (ALMA). The ALMA Scorecard tracks malaria related indicators in the areas of policy, public finance, financial control, commodities, implementation, and impact in addition to what are termed tracer indicators for maternal and child health. This publicly available scorecard enables countries to compare themselves and may serve to boost support for malaria and health programs. An example comparing Rwanda and Angola is seen in the attached chart.

We can conclude from the present situation that funding to sustain the current levels of progress against malaria morbidity and mortality is at risk, even though current levels are possibly only one-third of actual need.  Creative and alternative sources of funding are needed as well as better use of existing resources and greater national financial commitment in endemic countries.  Advocacy for improved malaria financing, while strong in the past, is just entering its most crucial phase.

Time Has Come for Stronger Domestic Funding of Malaria Programs

The changing scene among international donors points to a need to re-evaluate domestic contributions to finance malaria and other health and development programs.  Ethiopia is an example where policy thinking along those lines is underway.  The Voice of America (VOA) points out that, “Ethiopia stands out because it already has reached a 60% reduction in the mortality rate of children under five years old.” This progress has been facilitated by a decade of economic growth. VOA notes that although United States aid contributions to Ethiopia are now being reduced, Ethiopia is considering finding more domestic resources by scaling up a health insurance scheme that has been successfully piloted in thirteen districts.

Ghana has a long experience with its National health Insurance Scheme.  The World Bank reports that …

Ghana spends less than 5 percent of its GDP on health, slightly below average for a country at its income level. According to the 2009 World Health Organization (WHO) National Health Accounts, 47 percent of total health spending in Ghana is private (37 percent paid out of pocket and 10 percent paid by private insurance and other private risk-pooling mechanisms). Of the 53 percent public spending share, the NHIS accounts for some 30 percent of public spending on health and 16 percent of total health spending. According to the NHIS, active membership in 2010 was 8.16 million, some 34 percent of the population. Since 2005, outpatient visits have increased by a factor of 23, inpatient service by a factor of 29, and expenditures by a factor of 40. (Schieber G, Cashin C, Saleh K and Lavado R. Health Financing in Ghana. International Bank for Reconstruction and Development/The World Bank, 2012, Washington DC)

There are some caveats with health insurance. “Although the benefit package of insurance is generous, insured people still incurred out-of-pocket payment for care from informal sources and for uncovered drugs and tests at health facilities. Nevertheless, they paid significantly less than the uninsured.”  In addition ability to pay premiums initially or in subsequent years is a concern. Obviously poorer people are affected more by the premiums, and that was why people were hopeful about Affordable Medicines Facility malaria (AMFm) though out of pocket (OOP) expenditure was still required of the poor. The Global Fund did not cancel AMFm when its Board last met, but it did bundle the concept into existing and future malaria grants should countries wish to do so, leaving this subsidized treatment option, often through the informal private sector, in limbo.

domestic-funding-sm.jpgFunding levels are not the only concern in reaching and sustaining malaria targets. One also needs to concentrate on how the resources are being used. The Guardian recently described how top-down commodity distribution approaches need to be complimented with bottom-up community approaches. Without community understanding and demand net deliveries from donors may sit in warehouses for months and when they reach the community they may be used as fishing nets or even wedding dresses, according to The Guardian.

International partners are quite aware of the need for better use of resources. The World Health Organization’s Global Malaria Program GMP in revising its guidelines for malaria treatment in 2010 stated that, “The scale up of diagnostic testing will improve patient care (and) make more efficient use of scarce resources (emphasis added).”

Overall domestic funding has accounted for about one-fifth of total malaria expenditure in recent years. While this may not be enough, it is this contribution and better use of available funds that may pull us through to 2015.

Malaria Funding from the Perspective of International Donors

The recently released 2012 World Malaria Report (WMR) brought in to focus both malaria progress as well as the charges in malaria funding for the 104 malaria-endemic countries. Increased rates of coverage with vector control and malaria case management measures has mean that 274 million cases and 1.1 million deaths have been averted between 2001 and 2010. Unfortunately, The WMR observes that, “The enormous progress achieved appears to have slowed recently. International funding for malaria control has leveled off, and is projected to remain substantially below” projected needs.

We are not talking about small amounts of money or minor contributions to date. The WRM reports that, “The past decade has witnessed tremendous expansion in the financing and implementation of malaria control programmes. International disbursements for malaria control rose steeply from less than US$ 100 million in 2000 to US$ 1.71 billion in 2010 and were estimated to be US$ 1.66 billion in 2011 and US$ 1.84 billion in 2012.” This must be put in context with amounts estimated to be needed to achieve universal coverage (including use) of the major prevention and treatment interventions.

The WMR explains that “The enormous progress achieved appears to have slowed recently.” As noted above international funding for malaria control has leveled off, and “is projected to remain substantially below the US$ 5.1 billion” annually required to achieve and maintain universal coverage of malaria interventions. The Roll Back Malaria Partnership has estimated a higher projected annual need. “Resource requirements for global malaria prevention, control and elimination were estimated in the GMAP (Global Malaria Action Plan) to amount to some US$6.1 billion annually between 2012 and 2015.” This figure includes both program management costs as well as research needed to develop new tools.

The link between funding and coverage is clear in the WMR. The number of ITNs procured in 2012 (66 million) is far lower than in 2011 (92 million) and 2010 (145 million). “With the average useful life of ITNs estimated to be 2 to3 years, ITN coverage is expected to decrease if ITNs are not replaced in 2013.” Recent reports from a regional malaria elimination meeting in Kigali show that replacement time may be even shorter, possibly every 18-24 months based on local use and environmental conditions.

When identifying what is happening in malaria financing, it is important to recognize that there are relatively few direct donors. Major international malaria funders accounting for over 90% of donor financing are Global Fund, US President’s Malaria Initiative (PMI), Department for International Development (DfID), World Bank, and AusAid. Others include bilateral assistance, corporate donors and foundations.

international-funding-sm.jpgThe Global Fund as an entity and as the sum of its country contributors shocked the malaria and global health communities in 2011 when it announced the cancellation of its Round 11 of annual funding. The situation was complex and reflected weak financial pledging and inputs as well as internal management issues. The new funding approach was discussed in the WMR.  There are some uncertainties causing concern for the malaria community.

According to the 2012 WMR, “countries will be grouped by the Global Fund into Country Bands based upon a composite score which is a combination of a country’s GNI and its disease burden. Then there will be a “global disease split (i.e. 52% for HIV, 32% for malaria and16% for TB), until a new formula is determined, the Board,” that will be combined with a split according to Bands.  Finally actual allocation decisions will be made by the country coordination mechanisms (CCMs).  Malaria appears to be in greater direct competition with the other two diseases than what obtained in the past.  How other donors will compensate for any country shortfalls is unknown at present.

One possible implication of bands is that there may be less focus on lower burden countries that are heading toward malaria elimination.  Just because disease burden is low, or becomes low due to effective intervention does not mean that funding is not needed. Continued surveillance and case containment activities are not cheap, and require constant vigilance and sustained efforts since not all of one’s neighboring countries are at the same stage of malaria elimination.

RBM Harmonization Working Group Confronts Malaria Program Challenges

The 13th meeting of the RBM HWG is taking place inrbm-sm.gif Dakar, Senegal this week. Some thoughts about the. Current status of malaria programs emerged from member experiences and are shared here.

Since the cancellation of the Global Fund Round 11 may have been denied around one billion dollars annually. If funding does not fully resume until 2014, we could be looking at nearly $3B loss.

In the meantime there is need to help countries spent what remains most efficiently. Effort to secure approval for phase two renewal of existing grants is a priority.

Some countries may have many donor partners but still face problems due to lack of coordination. Problems come when countries do not budget for major activities likely implementation of LLIN (net) campaigns. Procurement and supply management problems persist. Stock-outs are the resulting “disease” but we need to find the root causes.

Not all partners bring funds and commodities, but their input is still important. For example Peace Corps has been making important contributions in advocacy and community education.

When there are funding gaps we need to document the impact. Lives may be lost. Advocacy is needed using country case studies.

As malaria prevalence reduces there is still a possibility of outbreaks, especially in context if cross border situations. Better epidemic response planning is needed with full collaboration of neighboring countries. The challenge is that funding is still country based.

Vigilance is needed to determine how the new Global Fund financing processes will affect malaria prospects.

Global Fund Observer on Uganda Malaria Funds

Issue 204 of the Global Fund Observer explains efforts to clarify funding challenges with the Ugandan malaria grant from the Global Fund. Their posting is shared below to increase access to this information. The financial problems have extended over several years, and GFO provides links to its previous articles on the problem, of which putting money into personal bank accounts was just one example.

gfo-logo.jpgNEWS: Uganda and the Global Fund to strengthen control and financial oversight of anti-malaria programmes: Global Fund insists on refund of ineligible expenses: PR told to stop transfers of malaria programme funds to personal bank accounts

The Global Fund and Uganda’s Ministry of Health are implementing a plan to safeguard Fund disbursements in the country following concerns over possible mismanagement of a $51 million grant to support antimalarial bednet distribution. The principal recipient (PR) for the grant was the Ministry of Finance, but the implementing entity was the Ministry of Health (MOH).

The Fund said in a statement that options to strengthen financial oversight and management to mitigate the risk of fraud are also being discussed.

The statement follows a review by the local fund agent, PriceWaterhouseCoopers Limited Uganda, which was commissioned by the Global Fund. The purpose of the review was to assess part of anti-malaria support programmes which involved the procurement and distribution of over seven million insecticide-treated nets to pregnant women and mothers with young children. As a result of the findings from this review, the Global Fund asked the LFA to expand its review even further.

Meanwhile, Uganda’s MOH carried out an internal audit to verify expenditures and address the internal control weaknesses.

The Fund said in the statement that it instructed the PR to discontinue transfers to individual personal bank accounts of funds intended for programme implementation. The Fund has also warned Uganda that it will seek a refund of all improper payments related to the $51 million grant for supply of anti-malarial bednets, and will insist on appropriate disciplinary action against anyone found to be involved.

Global Fund programmes in Uganda currently provide ARV treatment for 291,000 people and have distributed 7.7 million insecticide treated nets. According to the country’s Malaria Control Strategic Plan, malaria kills between 70,000 and 100,000 people in Uganda annually.

A detailed account of the genesis of the problems facing Global Fund grants in Uganda can be found in GFO issues 90, 103, 113 and 125. [This article was first posted on GFO Live on 21 November 2012.] To comment on this article at the GFO website, click here.

Stock-outs: how can we achieve malaria treatment goals?

Of twenty-two malaria endemic countries in Africa that receive support from both USAID/PMI and the Global Fund, eleven reported gaps in malaria medicine funding in the 2011 Road Maps countries prepare for Roll Back Malaria.  Likewise, 16 of these countries reported gaps in RDT financing and supplies.

dscn0296sm.jpgThese stock and procurement problems arise from many causes including ability to forecast need,  poor donor coordination and leadership, and lack of adherence to new guidelines that require diagnostic verification of malaria before treatment among others.  We are well past the 2010 RBM target date to achieve 80% treatment coverage, but the most recent DHS and MIS results from the 22 countries for appropriate treatment of children below five years of age show that the country with the highest achievement of ACT coverage in this age group was Malawi with only 36.2%.  The median among these 22 countries was 16.5%.

Therefore, it was not surprising that The Citizen newspaper reported from Dar es Salaam that, “Thousands of Tanzanians have continued to die from malaria annually due to lack of medicines despite massive investment by the government and donors towards improved supply of relevant drugs in health facilities.” Apparently programs like SMS for Life and AMFm have not had their desired effects.

The Citizen lamented that, “Phone calls to the CEO of Medical Stores Department (MSD), which is charged with responsibility of distributing drugs in the country, went unanswered.”  Other malaria implementation partners gave their own views that the problem was due to lack of professionalism among health officials and a lack of commitment to implementing the malaria program.

If we cannot even achieve malaria treatment targets by 2010, what hope do we have of reducing mortality by 2015 – let alone head toward elimination? Technical assistance may be needed, but cannot succeed if there is a lack of will on the part of program implementation partners from the endemic countries.