Tropical Health Matters

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.

… NEWS: 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.

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.

These 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.

By the end of this week someone will be nominated to replace Robert Zoellick as President of the World Bank.  Traditionally this nomination has been made by the United States, and it appears that this tradition is likely to be maintained.  The question is whether the traditional nominee – a white, older male of US citizenship – will be able to lead the World Bank in the Twenty-first Century.

The Washington Post today features two articles on this critical rite of passage. Howard Schneider raises, “The question now is whether the bank’s new leader, who could be named in the coming days, can enhance the institution’s role at a time when developing countries are emerging as the engines of world economic growth.” The mixed roles of the Bank – lender, donor, provider of technical assistance – and the emergence of other major and upcoming economic strong houses leads Amar Bhattacharya of the G-24 Secretariat to ask whether there is a clear goal for the institution at this point in time. His answer is ‘No.’

In contrast Michael Gerson sees a positive future because Zoellick’s leadership, he believes, leaves the “rarest of legacies: a multilateral institution with its reputation enhanced. Zoellick acted decisively to help stabilize the finances of struggling nations during the worst of the financial crisis, as well as to provide relief to countries hit hard by a worldwide spike food prices. He has increased transparency at the bank while successfully raising funds to recapitalize it.”

Gerson stresses the Bank’s need to listen to countries that receive its loans or grants since he sees no ‘silver bullet’ emanating from external development or aid experts. He traces as an example the evolution in country needs and requests from Rwanda which asked for emergency food aid in 2007, but a few years later sought investments to increase agricultural productivity and “Now is asking for help building storage facilities, so expanding crop yields are not wasted.”

Schneider does stress that the technical knowledge provided by the Bank is of equal importance as the financial resources it can mobilize. Who then is in the best position to marshal needed technical inputs while at the same time maintaining a humble leadership style that emphasizes that we need to learn from the low and middle income countries themselves?

According to the Washington Post, the current suspected nominees have ranged from Hillary Rodham Clinton and Sen. John Kerry to Susan Rice and Lawrence H. Summers, though for various reasons these have said they are not interested or are unlikely choices.

Jeffrey Sachs has let it be known that he is interested in the job, though Schneider notes, “But he says the administration has not approached him.” Sachs is certainly familiar with the needs of low and middle income countries, but would he or the other US candidates take a learning, rather than a prescriptive approach to working with these countries?

Another name breaks the US white male mold – Nigeria’s Finance Minister and Coordinating Minister for the Economy, Dr. Ngozi Okonjo Iweala. CP-Africa recently reported that, “Dr. Okonjo Iweala reportedly recently told the BBC that it is time to open it up to competition and that top jobs at international institutions should be filled on merit.”  They also though that such an appointee would only be successful with support from China.

What is at stake for the malaria community? Currently the World Bank has commitments for malaria control in 21 African countries up to US$ 762.8 million.  This has been used to finance over 73.8 million treated mosquito nets and 25.3 million doses of effective malaria medication over the past five years, a major dent in the overall efforts to scale up malaria control.  Given the current questionable status of Global Fund support, efforts by all other partners including the World Bank are crucial.  Hopefully the new leadership at the Bank will sustain this in line with the commitments of each national malaria control program.

The American Society of Tropical Medicine and Hygiene’s 60th annual meeting began today in Philadelphia with a keynote talk by Jeffrey Sachs, Director of the Earth Institute at Columbia University. The talk echoed Sachs’ recent online writings about the uncertainties in Global Fund support from major donors, especially the United States. But first the good news.

Sachs reminded the audience that this year marks ten years of Global Fund existence.  In that time, he explained, many new malaria technologies have become available ranging from an alphabet soup of ACTs, RDTs, LLINs, IPT, SMS and more.  This period has also seen a major increase in global malaria financial support (World Bank, Global Fund, PMI, etc.,) from $0.2 billion in 2004 to $1.8 in 2010.

Sachs cautioned that figures in the millions and billions were not the usual grist of macroeconomists who prefer to consider the movement of trillions of dollar or more. And yet, he noted that even with this scale up over the years, millions of malaria deaths have been averted.

Then came the challenges. Global Fund support has been mostly used for commodities, as ‘acronymed’ above. What is needed are string primary health care systems, including community health workers, to deliver these interventions.  Sachs stressed that such commodities should be free to poor people, and that social marketing strategies were actually a death sentence to poor people who could not protect their families without free and equitable access to these services.

Finally, the bad news. Sachs called our current situation with Global Fund a crisis in development assistance.  He described the crisis in terms of …

• Unprecedented attaches on development assistance by Republican candidates for the US Presidency
• Lack of current White House Leadership
• Cancellation of Global Fund Round 11

Sachs wondered whether the Millennium Development Goals can now be achieved. He concluded that gains against the diseases are all at risk, and that we are on the edge of collapse after ten years of work.Clearly much of the research and programs discussed at this weeks meetings will be threatened by expected cuts in development assistance, but more importantly, lives that the rearch and programs could benefit are at greater risk.

This morning two key advocacy groups organized a teleconference with Christoph Benn, the Director for the External Relations and Partnership Cluster at the Global Fund to Fight AIDS, TB and Malaria, so that we could learn more about the recent GFATM Board Decision to cancel Round 11 proposals/funding. The main take away message is that the GFATM is NOT in an immediate financial crisis, but that longer term projections could be at risk.

Christoph Benn was reassuring about the ability to carry on and scale up commitments made for funding rounds 8, 9, and 10. Organizers of the teleconference, the Foundation for AIDS Research (amfAR) and Friends of the Global Fight (Friends), encouraged participants to strengthen advocacy efforts with the US Congress where the longer term challenges lie in getting pledges for future funding.

There was talk of the GFATM 2012-16 Strategy that calls for funding based on national policies, national need (gap analysis) and dialogue with partners.  Christoph Benn indicated that Round 11 would have been the last of the formal funding rounds as we have known them, and its cancellation simply pushes us faster towards the new funding strategy. It was also made clear that there would be a weaning of G20 countries off of GFATM money, though commitments to high risk target groups in existing projects would be honored until those grants closed.

Again the short term effect is that countries that would have needed Round 11 funding will be encouraged to apply for transitional funds that will hold them over until the 2012-16 Strategy is fully implemented.  The Roll Back malaria Harmonization Working Group, for example, will be helping countries who intended to apply for malaria grants in R11 to undertake their gap analysis and planning in order to obtain transition funding.  This can only happen after the GFATM revises the application guidelines. As Christoph Benn explained, the ramifications of last months’ Board meeting in Accra are still being worked out.

Back to the longer term concerns or what was termed the uncertainties  of funding forecasts based on donor conditions.  Many donor countries have pledged to continue their funding levels to GFATM, and the United Kingdom has even pledged an increase. But all eyes are on the U.S. Congress, who initially pledged to maintain level funding this past summer, but now is uncertain whether global health and foreign assistance will receive support. It was basically this change of heart that put the brakes on R11 funding.

Our advocacy partners had heard from members of the Congress that they were worried about the financial health of the GFATM, but now have been told that the GFATM is still very much viable.  It is the longer term expansion beyond current commitments that is in question.  Rephrasing Jeffrey Sachs’ concern, “Will Washington leave millions to die?”

Just as the Asia Pacific Malaria Eradication Network’s community engagement workshop was ending in Chiang Mai Thailand, word reached the group that the Global Fund had cancelled its call for Round 11 funding. During the workshop participants and facilitators had discussed the community systems strengthening potential of Global Fund grants and how this could benefit APMEN counties’ community engagement strategies.

The Global Fund euphemistically phrased this cancellation at the just completed Global Fund Board meeting in Accra with a key decision point that notes the Board “Agrees to establish a Transitional Funding Mechanism … in order to provide this continuation funding (and) Decides to convert Round 11 into a new funding opportunity …”   Jeffrey Sachs clearly laid a large portion of the blame on the U.S. Government, which is responsible for about a quarter of the Global Fund project money when he observed that the U.S. …

… had pledged $4 billion during 2011-13 to the Global Fund, or $1.33 billion per year. Now it is reneging on this pledge. For a government that spends $1.9 billion every single day on the military ($700 billion each year), Washington’s unwillingness to follow through on $1.33 billion for a whole year to save millions of lives is a new depth of cynicism and recklessness.

The APMEN meeting therefore closed with a call on donors to honor their commitments to the Global Fund and the community programs it makes possible.  The final session was also devoted to action planning that included brainstorming by country teams of alternative funding sources to support community engagement.

Gawrie Galappaththy from Sri Lanka expressed clearly the workshop participants’ surprise and disappointment over the Global Fund announcement.  “Many of our countries have been receiving Global Fund support since 2003, and we are collectively dependent on the Global Fund from its different rounds. The reality is that with Global Fund support being so regular, governments have shifted some of their financial support for health to other areas. An abrupt stop to Global Fund support will hit us hard.  It will be necessary to regenerate the political will all over again for malaria and health.”

Gawrie also worried that, “Malaria is a dynamic disease. If we let the pressure off, it will re-grow as happened after the first eradication effort.  If we can’t get this elimination done now, we may never have a chance to do it again.”

The Globe and Mail summarizes the problem succinctly. “The global economic crisis has claimed a new victim: a $22-billion (U.S.) health fund that has saved millions of lives in Africa and other low-income regions during the past decade… The cuts by donor governments are not just because of the economic slowdown and the financial crisis in Europe, but also because of concerns over corruption in several recipient countries.”

The BBC interviewed the HIV/AIDS Alliance on this issue, and not surprisingly learned that this is the worst of all possible times to see cutbacks in funding for disease control.  The Alliance’s Director mentioned issues that could equally apply to malaria when he said that, “These should be exciting times – the latest scientific developments …”  New vaccines, new medicines and strengthened community participation strategies are just a few of the latest malaria developments that could be threatened.

Community engagement does take time and effort, even if it does not cost anywhere near the price of nets and drugs. Communities bring valuable resources to the table, but at the same time we do not want to foist malaria control and elimination responsibilities off on vulnerable poor people in developing countries.  APMEN workshop participants are going to be engaged in advocacy themselves, and are optimistic that donors old and new will not let communities down.

The Global Health Council’s Malaria Round Table shared the information that follows.  Reducing the already tiny USG commitment to international development would not only be mean-spirited, but would jeopardize global security.

This Thursday, November 3^rd, the Senate is likely to begin consideration of the State & Foreign Operations bill, probably as part of a “mini-bus” package with other components of the FY2012 Budget. With the current Continuing Resolution set to expire on November 18^th the Senate is under pressure to pass a bill to fund the government over the next fiscal year.

The Senate State/Foreign Operations bill is $5 billion higher than the House number, including a $700 million higher mark for global health. We need to do all we can to protect this higher funding level for global health and international affairs.

Call your Senator and urge them to protect funding for global and international affairs, and oppose all cutting amendments on the State, Foreign Operations bill during floor consideration and rejection of all harmful policy riders.

Talking Points

·         For less than 1% of our federal budget millions of lives are impacted each year. U.S. investments in global health have:

• Treated more than 3 million people living with HIV and prevent HIV transmission among millions more;
• Cut  the number of malaria cases by more than 50% in 43 countries in the last 10 years;
• Contributed to immunizing more than 100 million children each year;
• Treated 10 million people with tuberculosis;
• Delivered more than 255 million treatments to approximately 60 million people  for neglected tropical diseases;
• Increased the number of skilled birth attendants present during deliveries; and
• Supported research to develop and deliver new vaccines, drugs, and other critical health tools.

·         Further cuts to global health and international affairs programs would put lives at stake, threaten our diplomatic standing in the world, and put thousands of current and future American jobs in jeopardy. 

Putting Lives at Stake:

 

Global Health dollars support American jobs.

·         In 2005, global health activities generated $1.5 billion in Washington state and created or sustained more than 14,125 jobs.

·         In 2007, the global health sector supported more than 7,000 jobs and $508 million in salaries and wages in North Carolina.

Our colleagues at the West Africa Regional Network (WARN) of the Roll Back Malaria Partnership have been deliberating on the challenges facing countries in signing their Global Fund Grant Agreements. Many people do not realize that even when the GFATM Board approves a grant proposal, the grant does not become effective until a country prepares plans for implementation.  Only after such are approved, is the grant signed.  Below are observations and concerns from the WARN Secretariat.

Only two countries in West Africa were able to sign round 10 (Sierra Leone and Cap Verde). WARN noted that the countries that did not sign Round 10 or phase 2 of their grant registered significant delays due to:

• Lack of understanding regarding the conditionality to be fulfilled before the signing
• Cumbersome administrative procedures and communication bottlenecks between the countries and the Global Fund during negotiations

WARN Recommendations to the countries, Partners and PRs:

• Secure the support of the network of partners all throughout the negotiations process
• Involve local partners and WARN in the final grant negotiations with the Global Fund

WARN Recommendations to the Global Fund:

• Send a team to the relevant countries to explain conditionality and make proposals for immediately resolving problems encountered
• Send clearly stated correspondences to the countries and RBM partners indicating the planned date or period for the signing, failing which, the Portfolio Manager should provide the countries with explanations for the delay in the signing

It is likely that WARN is not the only region experiencing these problems.  As international funding support for malaria programs is threatened, Global Fund needs to ensure that whatever is available reaches those in need in a timely manner.

The publication this week by African Leaders Malaria Alliance (ALMA) of progress reports of African nations toward controlling and eliminating malaria and other maternal and child health problems has been both enlightening and helpful for advocacy and planning.  If one combines these data with reports by the Roll Back Malaria Partnership (RBM) on progress towards country Roadmap targets, a good picture emerges of the steps needed to reduce malaria deaths by 2015.

The time frames of the two indices are different – RBM is looking at overcoming gaps laid out by national malaria programs in 2010, while ALMA – but they are close enough to highlight the main logistical, process and input challenges facing endemic countries. The ALMA scorecard does have one outcome indicator – operational coverage of long lasting insecticide-treated nets (LLINs) – but one needs to consult surveys such as the Malaria Indicator Survey to get more accurate coverage data, and such surveys are scheduled less frequently.

Several key issues arise from these two reports.  For example, the ALMA Scorecard shows that eight countries do not have a policy that enables community case management of malaria, a strategy that is essential for achieving universal and timely coverage of malaria treatment. Though not indicated clearly, such a policy should include the use of rapid diagnostic tests (RDTs) and the community level.

Sixteen countries do not have full funding for purchasing the RDTs they need. RDT supply problems also appear in the RBM Roadmap analysis. Eighteen countries lack full financing for their LLIN needs.  Unfortunately, if not enough funding is available to achieve universal coverage now, what will happen in three years when most of the recently distributed nets may need replacing?

Of course there are hopeful signs. The Scorecard shows that ten countries have reduced malaria deaths by more than 50%, and another seven have made substantial progress. It is unfortunate that the remaining countries are left blank implying that there are inadequate data to make such calculations.  We will have trouble eliminating malaria is our monitoring and evaluation systems cannot measure progress towards our goals.

Hopefully such tools as the Roadmap analysis and the Scorecard will spur some friendly competition among malaria endemic countries in Africa that will save more lives and boost national economies.

Dr Coll-Seck, the Executive Director of the Roll Back Malaria Partnership reminds us that, “Since the moment when advocacy efforts shifted malaria from a neglected disease to global health priority, the results were tangible …

• a 30-fold jump in international funding
• increased commitment by African leaders
• a rapid expansion of research and development, and
• the creation of new alliances addressing malaria

This update is telling in what is not said. What is the financial value of the “increased commitment by African leader”?

Dr Coll-Seck adds that, “Change has been most dramatic in Africa, where enough insecticide-treated mosquito nets have been delivered to cover 76 percent of people at risk and 11 countries have reduced malaria cases and deaths by more than 50 percent,” but also cautions that, “these gains are as fragile as they are impressive.”

One of the factors that make these gains fragile has been the ‘fragile’ performance of some national Global Fund Principal Recipients in using their hugely increased donor support.  The Global Fund’s Office of the Inspector General has issued a plethora of abuse reports over recent months about misuse and fraud – Mali, Nigeria, Djibouti, Mauritania and Zambia to name some.

Even when funds are not abused, they may not always be put to the best use. Uganda plans a outreach effort to make malaria interventions available at the village level. The plan includes, “plan, a batch of 110,000 bicycles, 110,000 T-shirts and 110,000 medicine kits will be disbursed to every district to be used by the village health workers. The project will cost the government 6 million dollars.”  Support for village volunteers is crucial, but if volunteers are selected from the smallest community unit/settlement/hamlet, they will not need bicycles to move around.  If supplies are made available at a nearby central point, they will not have to travel far.

A combination of donor fatigue, financial crisis and recipient abuse does make the funding situation fragile. How can we guarantee resources to reach 2015 and beyond?