Tropical Health Matters

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?

The Daily Trust Newspaper today has a shocking front page headline: ‘N7bn malaria, HIV funds frittered’ (that’s Naira). This is equivalent to US $475 million. No principal recipient (PR) appears to be left unscathed. Specifically the article leads with the assertion that …

About N7 billion donor funds sent to Nigeria for the fight against malaria, HIV and tuberculosis were frittered away, according to an audit report by the international agency that provided the funds. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) said in a report filed with the Independent Corrupt Practices Commission that beneficiary agencies failed to account for up to $475 million meant to “save lives”.

The story is based on a report from the Global Fund’s Office of the Inspector General (OIG) who discovered “the fraud in a recent audit of 15 grants amounting to $474,519,260 disbursed between 2003 and 2009 for the purpose of saving lives in the country.” Nigeria has had three GFATM malaria grants over this period.

As is usual though the OIG paints both ‘minor’ accounting problems as well as gross misconduct with the same brush. The most egregious offender appears to be the Yakubu Gowon Centre (YGC). YGC has been a malaria PR since Nigeria received its first GFATM grant and almost lost that grant due to poor performance about five years ago.

Currently YGC is one of three GFATM Round 8 malaria grant PRs.  In terms of the most current performance ratings, The Society for Family Health was rated B1, The National Malaria Control Program was rated B2, while the YGC received a ‘C’ – the lowest or a failing grade by Global Fund accounting.

The Daily Trust quotes the OIG report The report thus: “The value for money audit report indicates that the Yakubu Gowon Centre for International Cooperation illegally transferred funds outside the country amounting to $15.5million, incurred extra budgetary expenditures of $5.2m, and had undocumented expenditures amounting to $3m. The unretired expenditures of the centre for the period under review amounted to $1.2m, while the management fee not accounted for was $659,000.”

The GFATM progress report says of the YGC performance on the Round 8 malaria grant that the average programmatic performance is 34.7% among all the program targets.  In fact some states served by the YGC are reporting stock out of malaria drugs much needed for saving lives.

It is certainly good that the IOG identified major misconduct that threatens progress to control malaria. The question is who will pick up the slack in malaria commodity supplies while all this is being sorted out?

China has recently made the news because grants from the Global Fund have been frozen over non-adherence to GFATM procedures. As reported on Yahoo Health News a spokesperson for the Global Fund said, “We believe that the main recipient, the CDC (China Centers for Disease Control), had violated an accord of the Global Fund which said that a part of the financing accorded, at least 35 percent, must go through community organisations.” As Yanzhong Huang explained, “The (Chinese) government may like the Global Fund money, but it obviously does not like the Global Fund’s ideas as far as civil society is concerned.”

To date, China has been awarded 14 GFATM grants covering all three diseases. Generally the grants have performed well. These grants have a lifetime budget of nearly $2 billion of which nearly $1 billion has been approved.

Let us compare this scenario against the world economic picture. Last August the New York Times reported that, “After three decades of spectacular growth, China passed Japan in the second quarter to become the world’s second-largest economy behind the United States, according to government figures released early Monday.”

To date China has pledged $30 million to the GFATM, and paid $20 million. China is not the only recipient country to contribute. Even Nigeria, whose economy is nowhere near as large as China’s has pledged $29 million and paid $19 million. Other recipients who have provided some support range from Malaysia to Rwanda.

In the end when one looks at a $30 million pledge compared to $2 billion worth of gain by the second largest economy in the world, one wonders why China does not or can not shift over to the donor side of the equation completely.

The thoughts of Yanzhong Huang on how to deal with this situation might be construed as appeasement. “In order to encourage the participation of China’s civil society groups in global health, it is important to allay the fears of Chinese leaders.” A harsher approach might be to say that if China no longer received GFATM money, there may be no need to allay fears. As the world economy slows, more of the G20 countries need to think seriously about how they can step up to the donor table and behave as if it were better to give than receive.

The Global Fund to fight AIDS, TB and Malaria (GFATM) represents a different business model in international health and development aid. Unlike traditional aid agencies, the GFATM does not maintain a direct in-country presence of technical and administrative staff who work directly with counterpart local agencies to develop plans for funding.  The GFATM’s business model basically raises funds and turns these over to local recipients (government ministries, national NGOs, international partners etc.) who have submitted technically and financially feasible proposals during annual funding rounds.

These local recipients set their own targets and basically are given enough rope to succeed or to hang themselves.  The latter appears to have garnered the attention of the international media after several grants have been suspended and words of caution have been directed at others who not only have not achieved their self-set targets but appear to have misappropriated, misused or otherwise ‘lost’ some of their funds. One recent account shows that such loss may be in theft of product, not just straight-forward embezzlement of funds.

Local recipients receive some oversite in terms of both expenditure and achievement of program targets. In theory the local recipients – both Principle Recipients (PRs) who are money managers and Sub-Recipients (SRs) who are program implementers – are screened and approved by a national Country Coordinating Mechanism (CCM). The set of projects in a country are also overseen by a Funds Manager based in Geneva who reviews reports and makes occasional site visits.

There are quarterly progress reports submitted through CCMs to independently contracted Local Fund Agents (LFAs), who in the past were more of accounting firms, but apparently now can also ‘audit’ technical aspects, and ultimately to GFATM itself. After two years (or functionally 18 months) each project is reviewed both finacially and technically and given a ‘Go’, ‘Conditional Go’ or a ‘No Go’ to enter ‘Phase 2.   This exemplifies another basic tenet of of the business model, performance based funding.

The GFATM is a consciously evolving organization and has conducted and contracted various evaluations in order to make decisions about program and organizational directions. Such have included the specific, a CCM assessment that identified the need to ensure these bodies were independent of government (or any other group) as well the general, a series of 5-year evaluations. As a result the GFATM has reconsidered funding processes and is evolving toward more alignment with national disease control strategic plans and less on focused annual funding rounds.

Another example of GFATM decision making based on evidence was the change in PR requirements for proposals. After an evaluation showed that NGO PRs performed generally better than government of international agency PRs, and also after it was found that NGOs better represent the interests of the recipient communities (e.g. people living with AIDS), the GFATM Board decided that all grant proposals should have at least one NGO PR.

In short, the GFATM has shown an ability to learn by actively seeking knowledge of its operations and make changes and monitor those.  Of course the recent reports from the Office of the Inspector General show that this is not an easy process to manage from afar given such a large portfolio.

The calls by some for the US Congress to do its own study of the stituation will hopefully not result in throwing the babies sick and dying from AIDS, TB and malaria, out with the bathwater. The GFATM has shown itself willing and able to change without such dire threats. We can still question whether the Global Fund would change its basic business model and become more than a funding agency.

Other aid partners are often left holding the bill for technical assistance to address needs and gaps in country programs. In theory country recipients can use their GFATM funds to pay for TA, but most prefer to go the guaranteed route of buying the commodities (that have gotten some in trouble). Agencies like WHO, USAID, DfID, Unicef, and the Clinton Foundation, to name a few, have always been willing in the end to cough up their own funds to support the TA that is not paid by the GFATM. This creates an uncomfortable marriage among aid agencies.

So maybe the Global Fund will preserve its business model, but if the Fund cannot or will not have a more active presence on the ground, maybe it should pay its aid partners to do this work, for which they have generously been using their own funds in desparation.

Tarry Asoka, a medical doctor and health development consultant, provides us a perspective on why health insurance is needed to meet malaria treatment gaps. Tarry is  Publisher/Editor of Health Insurance Affairs and Malaria Bytes…

All across sub-Saharan Africa the poor utilization of modern health services usually reverses and begins to improve, reaching a tipping point as soon as there is confirmed indication that ‘treatment charges’ in health facilities have been removed. And politicians in the sub region are very quick to take good note of this phenomenon – often taking full advantage to develop populist ‘free health campaigns’ that are often not sustainable.

The lack of continuity is not usually the result of faulty design but due to poor execution as many of these are mostly ad hoc initiatives rather than enduring programmes. But the fact that these campaigns continue to be popular especially among poorer citizens despite their lack of permanence and irrespective of who is organising it – government, NGOs or private – should give health planners some worry that something is not quite right.

Curiously, malaria is still the most common condition recorded by health professionals during such health jamborees. A recent free medical check-up drive to promote a new community-based health care programme in a high density area in Port Harcourt, Rivers State, Nigeria – noted that close to 30% of those who were seen had classical symptoms and signs of malaria that have not been treated for at least 2 days.

So what could have happened to such persons especially children if this event did not take place at that particular point in time? Your guess is as good mine.

But one fact is clear – the payments that are needed to be made at the point of accessing health services prevent large majority of the population from seeking medical care. A recent survey in Kenya, for example, found that “61.5% of individuals who did not seek (malaria) treatment reported that cash shortage was the main barrier.” Others coped by borrowing, selling household possessions, or buying cheap drugs from shops.

Therefore, any mechanism that enables people to access care ‘free at the point of delivery’ will improve treatment for life-threatening conditions such as malaria and save lives.

This is ‘no-brainier’, and does not require elaborate plans to be put in place. Apart from informal and community-based health insurance, which has been quite challenging to set up, other approaches such as vouchers and coupons have also proved to be useful alternatives.

The task now is to scale-up these options to achieve universal coverage.

Widespread efforts to scale up insecticide treated net ownership to meet 2010 Universal Coverage targets are underway in most endemic countries of Africa.  The majority have been using their Global Fund grants to make this leap, supplemented by contributions of other partners.

What happens when a country does not have Global Fund resources at this time? Current efforts in Sierra Leone to reach its nearly 6 million citizens provide a lesson on how to cope.

The AFP has reported on a “20-million-dollar campaign to distribute mosquito nets has been funded by the World Bank, the British Department for International Development (DFID), the Federation of the International Red Cross, the United Methodist Church and other health partners.” These partners are “attempting to get insecticide-treated mosquito nets into each household in the country and to ensure their proper use,” using a house-to-house campaign, which is challenged by poor road conditions.

VOA quotes Lianne Kuppens of Unicef in Sierra Leone who said, “”We have roughly 6 million people and we have 3.2 million bed nets already in the country as we speak. So it’s the first time ever that we are going for universal coverage of bed nets.”

Kuppens also noted that ITN use by children below 5 years of age was below 25%, a problem exacerbated by net mis-use – “nets often find their way into the marketplace or are used as fishing nets or shower scrubs. Vegetable growers use mosquito nets to protect cabbages and carrots from harmful bugs.”

VOA also reports that the campaign has a strong “hang up” component that is using “Street theatre, community radio and religious leaders (to) help convince people that hanging their nets over their beds is better in the long run than selling them or catching fish with them.”

But back to the Global Fund …

Sierra Leone’s experience with the Global Fund (GF) may certainly be influenced by its status as a post-conflict country.  The Principal Recipient of the current Round 7 Grant, the Ministry of Health, has, according to GF progress reports, experienced some management challenges.

The Round 7 grant has been running for 2 years and just recently received a “conditional Go” for Phase 2 funding.  ITNs were a small piece of this grant that aimed more at improving malaria treatment.  By 30th April 2010 the grant had distributed only 277,093 of a targeted 312,498 nets for young children and pregnant women.

While the GF does not attempt to strengthen health systems directly, it certainly makes it possible for countries to use grants for their own health system strengthening efforts. More countries should take advantage of this potential. In the meantime, partners should continue to pull together as is the case in Sierra Leone to ensure Universal Coverage.

This month marks the 4th year for Malaria Matters and our 500th posting. Two of our first postings we examined what happens to chloroquine when it is no longer used as a first line drug,and how malaria proposals fare at the Global Fund.

Chloroquine was valued because it was inexpensive and therefore justifiably used for presumptive treatment. Resistance showed not only that the presumptive treatment approach was likely flawed, but that single drug or mono-therapy treatments were not appropriate. Research today continues to document the spread of chloroquine resistance for example, in vivax and falciparum malaria in Indonesia.

What our 2006 posting addresses was the fact that chloroquine resistance did reduce after the drug is withdrawn as the front line treatment in Malawi. These findings were backed up by a study from Kenya published last year. The Kenya researchers reported “a reduction in resistance to CQ following official withdrawal in 1999 was found, but unlike Malawi, the decline of resistance to CQ in Kilifi was much slower,”ultimately taking twice as long as it did in Malawi – assuming use remains at a low level.

The practical research question moving into the future toward malaria elimination is whether an inexpensive drug like chloroquine can ever again find a place in the pharmacological arsenal against malaria. The experiences of both increasing and reducing drug efficacy also stress the importance of maintaining strong pharmaco-vigilence as part of any national malaria control effort.

Concerning the Global Fund we expressed disappointment in 2006 that malaria grants performed so poorly in Round 6 allocations in terms of relative proportion of total grants as well as proportion of submitted grants approved. Since that time the Roll Back Malaria Harmonization Working Group has mobilized human resources to strengthen the grant writing process. Since that time malaria grants have been gaining a greater share of total resources and have had better success in being approved.

According to AIDSPAN, this year’s Round 10 allocations may be a mixed bag for malaria. While 79% of submitted malaria proposals were recommended for approval (better than the 50% overall approval rate), only a small number of proposals were submitted (24) and ultimately approved (19) of the 89 from all sources.

This low ‘turnout’ may reflect the economic constraints at the Global Fund where there had even been some doubt earlier that a Round 10 would be issued, but it reflects poorly on the need to scale up and sustain malaria interventions into 2015 and beyond. This also does not reflect changes in Global Fund approaches such as the rolling continuation credit and the potential move toward funding based on national strategy, all of which are changes at the GFATM since 2006.

Overall once can see that in four short years the funding and technical landscape surrounding the control and elimination of malaria are changing quickly. We are closer now to a vaccine, WHO has updated its malaria treatment guidelines, long awaited rapid diagnostics tests are rolling out in larger quantities, and countries, such as those in southern Africa, that need to develop pre-elimination strategies are being identified. We intend that Malaria Matters will help you keep up with these vital changes.

The East African today noted that, “Every African business in malaria endemic areas knows all about high absenteeism during the malaria season.” This opinion article goes further to state that, “Health spending cripples African consumers and governments, the tax base struggles to expand and foreign investment is discouraged by high rates of illness among workers,” referring to HIV, TB and malaria.

The solution according to the East African is, “For the African private sector to maximise these returns, awareness must be raised of effective practices in engaging health, and the benefits of partnership towards this end … Using established multilaterals like the Global Fund is an effective way for the private sector to engage health goals while maintaining business focus.”

While these are good sentiments, in reality of private or non-governmental contributions to the Global Fund have been minimal. Currently private pledges to date account for 4.4% of the total pledges ($29,928,488,771) to the Global Fund and a slightly higher 5.0% of the total paid ($18,146,056,176). One donor, the Bill and Melinda Gates Foundation, provided around three-quarters of this support.

The next largest private sources are the Product Red Campaign, which has paid 17.4% of the total private contribution, UNITAID (4.3%) and the Chevron Corporation (3.3%). These Global Fund contributions do not measure the total private contribution of global disease control, which includes, according to the Global Fund …

• Marketing campaigns and financial contributions
• Pro bono services and core competency partnerships
• Support for advocacy and governance, globally and locally
• In-country co-investments and operational contributions

The private sector is an identified constituency of the Roll Back Malaria Partners Forum. According to RBM the contributions of the private sector are as follows:

• First, the private sector possesses a breadth of expertise and implementation skills – including delivering products and programmes in the developing world.
• Second, the private sector has a particularly important role to play in ensuring the supply and efficient distribution of drugs, diagnostics, LLIN’s and other interventions against malaria.
• Finally, the private sector can bring the “business mindset” to the RBM Partnership, with its emphasis on good management practices and tangible results.

Clearly such contributions are not limited to financial ones and address in kind provision of expertise.The list also does not clearly identify individual focused efforts such as the Obuasi IRS program of AngloGold Ashanti, ITN donations from the telecommunications company MTN, or support from corporations like ExxonMobil to bilateral programs like the US President’s Malaria Initiative.

But back to the East African … are these contributions commensurate with economic benefits that can accrue from the major internationally and bilaterally funded efforts to control malaria? The answer probably comes down to the country level.  Private sector partners need to participate actively in each national RBM partnership forum so that their presence, expertise and of course financial help, can be felt.

PS:

Two news stories in the Washington Post shed further light on the issue. The first shows the need for increased private giving because foreign aid may be in doubt … “even the administration’s ability to provide direct climate assistance to poor nations over the next two years is in doubt because a looming budget battle with Republicans could freeze U.S. foreign aid at this year’s levels, or even cut it.”

The second highlights private sector philanthropy in other countries. “As India’s wealth continues to expand, a growing number of millionaires here are finding ways to do more for the poor, especially as cash-strapped foreign donors, including the United States, curtail aid.” Major religions in India may play a role in encouraging charity. “Indian billionaires give more than billionaires in China but less than those in developed countries, including the United States.”