Tropical Health Matters

Kenya’s Saturday Nation reports that the country lost out on appeal for its Global Fund Round 9 malaria and HIV application rejection. “Late last year, Kenya’s (original) application for funding from the Global Fund on Aids, TB and malaria for $270 million was rejected on technicalities and the country’s poor record with the organisation.”

Apparently the rejection of the appeal was two pronged – proposal quality and past performance. First the Nation reports that, “On Kenya’s appeal for malaria funding for example, the panel upholds that the decision made initially by the technical team was sound and saw no need to reverse it.” Then the Nation quotes a Ministry official as saying, “Our under-performance has been the main undoing.”

To date Kenya has received only two malaria grants from the Global Fund – Rounds 2 and 4. Only 17% of the Round 2 funds were ever disbursed for the $27 million grant after start-up in 2003, and apparently the grant ground to a halt after about 3 years, never entering Phase 2.

So far 63% of the $162 million Round 4 grant have been disbursed since inception in 2006. Expenditures are only 60% of disbursement. On last review in November 2009 the grant scored a B2, meaning inadequate performance but potential demonstrated.  The difficulties in performance and new grant success seem ironic since Kenya has recently made major strides in updating its malaria strategy and action plans to better reflect the country’s epidemiological and transmission profiles.

On top of these problems were reports from Kenya early last year that “the Government appointed a taskforce to trace the missing Sh13 billion grant from the Global Fund to fight Aids, tuberculosis and malaria.”

Once grants have been made, the Global Fund’s Office of the Inspector General has a role in monitoring implementation and colating lessons learned to improve GFATM functioning. The most recent report notes that of 17 recommendations made to Kenya to improve the functioning of its grants, none were implemented. General problems across several countries included among others …

• Conflicts of interest with PRs and SRs sitting on CCMs
• CCMs micromanaging grants instead of overseeing them
• PRs not complying with grant agreement clauses
• Procurement not executed in line with best practices
• Weak financial management and internal control of PRs
• Unworkable monitoring/evaluation systems because of unattainable targets and poor data collection procedures (feature attributed to countring including Kenya)

None of the foregoing problems are secret, and yet countries like Kenya cannot seem to get out of the viscious cycle of poor performance leading to new grant rejection leading to funding shortages that lead to more poor performance in their malaria control efforts.  Back in 2008 Kenya went through major efforts to democratize and improve the functioning of its Global Fund governance mechanisms.  Maybe the malaria partnership has not help Kenya accountable for the promises it made?

PS – the Global Fund is not Kenya’s only weak area for international assistance. According to the Nation yesterday, “Kenya has failed the eligibility test for (US) Millennium Challenge aid in each of the past five years because it falls short on governance standards.”

Roger Bate and colleagues (Tren, Hess and Bate, 2009) are again challenging us to face up to problems with the procurement, supply and quality of malaria control medicines and commodities. Their article that appeared yesterday in Malaria Journal questions whether efforts to get supplies from the lowest price bidder pay off in the end.

Kenya and the Global Fund are the major focus of this analysis. Kenya’s Round 4 Malaria grant from GFATM has not had easy sailing and currently is rated at B2 – which means “Inadequate but potential demonstrated.” The grantee was plagued with considerable procurement and supply management (PSM) problems during Phase 1, when the Global Fund observed that, “Overall performance of this program has not been satisfactory to date.”

Prior to receiving approval for Phase 2 the Fund did note change: “The PR (had) considerably improved the PSM plan which was a CP (Conditions Precedent) for this disbursement and overall the revisions to the PSM plan address the majority of concerns raised at Phase 2 signature.” An innovation at address PSM was a ‘procurement consortium’ that would enable the Kenyan program to collaborate with experienced agencies and learn.  An observation by Amin et al., shows how this process was complicated by the way the Round 4 Malaria grant was set up initially.

The main challenge centered on how to manage the financial flows to make sure funds were availed in time for orders to be placed and processed. Theoretically, funds would flow from the GFATM, to the principal recipient (Ministry of Finance), then to the MoH (sub-recipient). The MoH would, after consultation with the national procurement consortium established to manage the tendering and ordering of commodities purchased with GFATM funds, place an order with WHO to forward the order to the supplier (Novartis Pharma AG in Switzerland).

This lengthy process was also highlighted by the Global Fund. “The PR (principal recipient) should also disburse directly to the Consortium, rather than through SRs (sub-recipients), in order to avoid excess bureaucracy and speed up the procurement cycle.”

The specific concern of Tren et al., is a recent effort by the Global Fund to ask some grant recipients to use international competitive bidding processes for certain drug purchases. In the case of Kenya “After awarding the tender for its annual supply of the anti-malarial artemether-lumefantrine to the lowest bidder, Ajanta Pharma, Kenya experienced wide stock-outs in part due to the company’s inability to supply the order in full and on time.”
The Global Fund itself states that, “The central objective of Global Fund procurement policies is to procure quality-assured products at the lowest price and in accordance with national and international law. Procurement must be conducted in a transparent fashion.” ‘Competitive procurement’ is mentioned in these guidelines, and WHO’s pre-qualification process for ensuring drug quality is stressed, though as Tren et al., point out, exceptions to the latter can be made.

Back to Kenya – Tren et al. have shown that delays in procurement have occurred with the Ajanta contract starting in 2008, but delays and stock-outs have been a common occurrence since the start of Global Fund malaria programming in Kenya.

One of the major procurement delays and inefficiencies, sending money into a country, converting it to local currency and then procuring from an outside source requiring re-conversion of the money, has been addressed partially by GFATM’s Voluntary Pooled Procurement (VPP). It was hoped that the labyrinthine procurement process among PRs, SRs and others in Kenya could have been ameliorated by VPP, but apparently this was not to be.

In the meantime Kenya has been turned down by the GFATM for all subsequent malaria grant applications since Round 4, in part due to poor performance linked with these procurement challenges.  Kenya’s only current GFATM malaria grant expires in less than 14 months. Somebody better get the procurement process right before then.

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.

The American Journal of Tropical Medicine and Hygiene is announcing as ‘good news’ the ‘remarkable malaria control progress and benefits on the island of Bioko in Equatorial Guinea over the last 4 years.’  Kleinschmidt and colleagues report –

• spraying IRS every 6 months in typically > 80% of households
• achieving 73% LLIN use (not just ownership) in households through house-to-house distribution with instruction and education
• achieving significant reductions in parasite prevalence, anemia and fever
• falling under five mortality from 152 per 1,000 births to 55 per 1,000

Steketee commends the strong public-private partnership that enabled this progress and recommends case containment and other strategies to solidify and sustain the gains toward elimination from the island.

Only one key component of the control strategy did not show progress – by 2008 coverage of pregnant women with two doses of intermittent preventive treatment (IPTp) was only 19%.  This component is not campaign based and requires strengthening the basic MCH services – so one wonders is the program to date has really strengthened the local health system to maintain the achievements. Then there is the Equatorial Guinea mainland to consider

Bioku Island is in the middle of the off shore oil fields, headquarters for the oil companies and an important tourist destination.  the benefits of controlling malaria in this powerful setting definitely have international economic ramifications for the local economy.

Apparently the poor people on the mainland are not being forgotten – in “2006, the partners secured Global Fund resources to expand the work to mainland Equitorial Guinea.”  The mainland is still a relatively small territory – and if Rwanda as a nation can make and achieve a commitment to control malaria, an oil rich nation like Equatorial Guinea should be up to the task of helping all its population.

The most recent Global Fund Malaria Grant performance information (April 2009) shows the Equatorial Guinea project performing at the B2 level.  This is at the bottom rung of acceptable performance.  There is mixed achievement on indicators as seen in the chart – IPTp seems better than on Bioku, but not everyone is sleeping under distributed nets. ACT case management training has started but no data are available to show if people have been treated. According to the Global Fund, “The program has faced significant delays due to long procurement process and treatment protocol approval but is now on track as drugs have been delivered.”

The Global Fund project has two more years to go – hopefully all partners – public, private, NGO, etc. – will pull together and help the mainland just as they have been willing to protect their interersts on the island.

Uganda’s New Vision newspaper points out that …

UGANDA has lost $12m (about sh25b) from the Global Fund over poor accountability. Out of $36m allocated to the country in 2003 for HIV/AIDS activities under Round One, over $10m has not been released as the Fund was not satisfied with how the first installments were used. Another $24m was allocated in 2004 for malaria activities under Round 2, but $2m has not been disbursed, according to the Fund’s website www.theglobalfund.org.

The Round 2 Malaria grant apparently was intended for only 3 years. It started in 2004 and the last progress report was posted in August 2007. In that last report the GFATM rated the project with its lowest grade, a ‘C’.  The currently running Round 4 malaria grant is rated at B1 as of February 2008.  There is no record that a grant agreement has been signed and disbursement commenceD on the Round 7 malaria grant that was awarded a year ago.

The Guardian reminds us that, “In 2005 Uganda was suspended from the Global Fund over irregularities in the administration of funds. This year, the Ugandan government began proceedings to prosecute those accused of embezzling Global Fund money, including two former health ministers.” The Guardian also points to health system challenges may be at the root of some grant performance problems:

Uganda’s decentralised health system is to blame for the poor delivery of health services across the country, according to health minister Stephen Mallinga. Speaking at the 14th health sector joint review meeting in Kampala on Monday, Mallinga said the decentralised recruitment of health workers had led to a culture of “tribalism”, with many health workers recruited and remaining within their own home regions.

Global funds are urgently needed in Uganda because as The Guardian pointed out, “Uganda’s economic woes continued this week with an estimated 114bn Ugandan shillings ($54m) wiped off the local stock market in one day.” The Global Fund website also featured Uganda’s economic problems by explaining that, “The future of Uganda’s recently launched five-year strategic plan aimed at reducing new HIV/AIDS cases in the country is uncertain because of the global financial crisis, which could lead donors to allocate funding more conservatively.”

Currency problems were also highlighted by The Guardian: “Last week the shilling collapsed against the dollar, falling to a low of Shs 2,200. As a result fuel prices have spiked, with a litre of petrol rising by nearly Shs 300.” Inflation is a major challenge to donor funding – assuming the $12 million in HIV fund are ‘found’, they would be worth much less today than when first awarded.

If GFATM malaria funds stop, the burden will likely fall on families. The Uganda Ministry of Health estimated that, “A poor malaria-stricken family may spend up to 25% of its income on malaria treatment and prevention.”

In these times of economic crisis donors like the Global Fund need to stress even greater accountability and performance than before to make every Dollar, Pound and Euro count.

The group Drive Against Malaria has focused on “malaria prevention for the Bantu and ignored Pygmy population in this difficult to reach area by distributing LLITNs and ACTs and providing diagnostical support,” in Cameroon.

It is not clear whether the Pygmy areas of Cameroon were intentionally left out of national malaria control plans, but the Global Fund Round 3 Malaria grant for Cameroon specified tha “Premises will be identified in the Far North, North, West, South West, North West, Adamaoua and Centre provinces, and provided with net treatment equipment and skilled staff to ensure training and quality control of the community treatment units.” Not mentioned were Littoral, South and East Provinces where pygmy populations are more common.

Even if there was no intentional neglect of this minority population, the reality of grant implementation shows that ITN coverage is far behind expectations. Even though retreatment centers have been set up in 6 provinces and around 900 communities, only 65% of the targeted children has been reached and 45% of the current target nets has actually been retreated three years after the grant started.The Global Fund concludes –

At the end of the third year of implementation of program activities, performance remains somehow not fully satisfactory. Delays in procurement of bednets have impacted the achievement of related targets, while the reporting of pregnant women receiving IPT is not fully convincing as data is based on estimation.

The figure below is extracted from the GFATM progress reports.

The Round 5 Malaria Grant is approaching the end of Phase 1. Efforts to ensure access to ACTs is proving challenging. In the most recent progress report one can see that  only 17% of targeted health facilities reported no stock outs lasting > 1 week of malaria drugs. Likewise only 62% of targeted health facilities had ACTs. Also only 43% of children under five in targeted areas received correct malaria treatment.

The Global Fund had this to say about the Round 5 grant performance: “Six months after program started, results are disappointing with only very few activities having been implemented.”  Clearly when grants don’t perform, minorities have a lesser chance of being served, assuming their regions, districts and communities are even targeted.  Greater accountability is needed.

Malaria control and immunization programs do work together in the form of national or local immunization campaigns where insecticide treated nets are also distributed.  There is an assumption that there will be a synergistic effect on coverage of combining these efforts, but an important question is whether the existing base platforms of immunization programs in countries can really deliver better vaccine coverage, let alone better ITN ownership and use.

Colleagues at the World Bank have conducted a qualitative inquiry into immunization program management to identify factors that might lead to success and thus, form the basis for more structured research.  The Expanded Program for Immunization has at least a 30-year history to draw on, and thereby, offers a good foundation for study.  The researchers chose the period 1997-2002 and looked at four sets of African countries: those with higher than average coverage that has increased over the 6-year period, those with high but decreasing coverage, those with low but increasing coverage and ones with both low and decreasing coverage.

In-depth study was conducted in six countries that covered the four categories of countries.  The study focused on five core management functions: 1) demand, 2) financing, 3) governance/institutional framework and the supply function which was divided into 4) management and 5) service delivery strategy.  A summary score of indicators achieved under each function yielded a 4-point score which is seen in the attached chart.

The authors noted that, “What distinguished the two high performers from all other countries in our exercise was a robust implementation of their immunization programmes. Only (those two countries) combined reasonably good governance and a solid institutional framework with reasonably good management, service delivery, financing and demand.”

The researchers suggested that, “One way that multilateral and bilateral partners in immunization may help is by offering countries  performance-based incentives without earmarking their assistance for specific functions.”

They also found that, “Reasonably good performance on at least some functions (the high but decreased coverage examples) appeared to be more beneficial to coverage than deficient performance across all (the two low coverage countries); doing a few things well, however, did not appear to be sufficient to ensure a high level of sustained success.”

Since wide scale implementation of malaria control is still coming on board in most countries, there are few examples of widespread intervention where a similar study could be conducted right now. Even so a preliminary assessment of factors that affect such management functions in crucial so that both scale-up and sustainability can be promoted until such time that eradication is truly feasible.

Simbarashe Musiyiwa of The Herald of Harare, Zimbabwe focused on HIV/AIDS in critiquing the slow progress being made in accessing money for two rounds of Global Fund projects in the country. “The Global Fund for HIV/Aids, Tuberculosis and Malaria has been challenged to stop politicising HIV and Aids funding and distribute the amount due to Zimbabwe in time as is has done for other countries in the region. Since Zimbabwe’s standoff with London began at the turn of the millennium, the illegal Western sanctions have been used to have the fund either deny Zimbabwe assistance for flimsy reasons or allot it amounts far below what other African countries get.”

The recently completed Zambezi Expedition passed through Zimbabwe and noted that, “Ongoing economic difficulties are obstructing malaria control efforts in a country which had historically made much progress in the fight against the disease.”

In addition to HIV, Zimbabwe has two malaria grants from the Global Fund, and a review of the progress reports on the Round 1 and 5 grants is instructive.  The most recent progress report (October 2007) on the Round 1 Grant shows that 70% of the &8.5 million project has been disbursed. The grant currently has an overall rating of B1, which is quite good. Progress has been made on some indicators as seen in the attached chart.

Furthermore the Global Fund has praised the CCM of Zimbabwe. “The CCM in Zimbabwe is considered one of the model functioning oversight structures within the region and is supported by a Secretariat with a full-time Co-ordinator.” In addition the Principal Recipient (PR), the Ministry of Health, is said to be performing adequately. “Overall, the Principal Recipient has demonstrated satisfactory management of the Round 1 Malaria grant. Technical assistance provided by WHO including the assignment of experts to the Principal Recipient, has contributed to the efficient management and oversight of imported commodities.”

This does not mean that there are no problems. One of the biggest concerns is inflation. In fact hyperinflation with rates exceeding 1000% mean that once money is received and exchanged into local currency it quickly looses value unless spent in a relatively speedy and efficient manner – a challenge to PRs in any country. Fortunately the Global Fund has means of buying commodities directly if countries request in order to avoid inflationary effects.

Round 5 Malaria Grant did start late – in October 2007 – but 24% of $28.5 million has been disbursed as of May 2008.  At least for malaria, the picture of disbursement and utilization of funds to achieve targets may not be as dire as the Herald implies for HIV grants. The Herald does report that an auditing team from the Global Fund is due in Zimbabwe soon. Hopefully this team will ensure that the fight against malaria does not stop even amidst the political and economic turmoil in the country.

RBM has interviewed the UN Special Envoy for malaria, Raymond Chambers and asked, “What needs to happen now so that Roll Back Malaria targets can be reached by 2010?” He responded, “That gives us a thousand days. We have to get all of our people working in the fields in cooperation with the local ministries of health; we’ve got to work with the manufacturers of the commodities for things like bed nets and medication and get them to have a schedule of delivery; we’ve got to accelerate some of the funding so that we can meet the requirements of the manufacturers of the commodities; and we’ve got to get everybody to buy into one plan. We’ve also got to ensure that plan is most effectively implemented and executed.”

As we have reported, countries like Ghana, Mali and Nigeria have a ways to go to achieve the 2005 targets of 60% coverage with ITNs, IPTp and appropriate case management with ACTs, let alone reach 80% or more. While all three countries have received Global Fund Grants, they have concentrated in large part on the public sector for service provision, and although they thereby reach their GFATM targets, they have problems achieving overall coverage goals.

Mr. Chambers is right, every partner – public, private and non-governmental, as well as the community – must come on board if 2010 targets are to be achieved. Often there is a reluctance on the part of the public sector, who often monopolize GFATM and other donor support, to ignore or look down on the private sector, especially the informal private sector such as medicine sellers. In rescuing its GFATM Round 4 grant, Nigeria came to the realization that the private sector is crucial and for Phase 2 selected an additional Principal Recipient to focus on this neglected component of malaria control.

Scale up to reach 2010 will be a challenge when we have yet to reach 2005 goals. We might have a chance if all sectors are involved in the partnership.

The G8 has just reaffirmed its pledge to support malaria and other disease control efforts in Africa and many countries are in the process of developing their Global Fund Round 7 grants. Therefore it is an interesting time to consider a 2005 Der Spiegel interview of Kenyan economist James Shikwati that calls on the industrialized world to STOP AID.

According to Shikwati, “Such intentions have been damaging our continent for the past 40 years. If the industrial nations really want to help the Africans, they should finally terminate this awful aid. The countries that have collected the most development aid are also the ones that are in the worst shape. Despite the billions that have poured in to Africa, the continent remains poor.”  Walter E. Williams of George Mason University echoed these views in the Baltimore Examiner on 28 June 2006 when he said, “No amount of Western foreign aid can bring about the political and socio-economic climate necessary for economic growth.”

Shikwati said the problem arises because, “Huge bureaucracies are financed (with the aid money), corruption and complacency are promoted, Africans are taught to be beggars and not to be independent. In addition, development aid weakens the local markets everywhere and dampens the spirit of entrepreneurship that we so desperately need. As absurd as it may sound: Development aid is one of the reasons for Africa’s problems. If the West were to cancel these payments, normal Africans wouldn’t even notice. Only the functionaries would be hard hit, which is why they maintain that the world would stop turning without this development aid.”

On the other side is praise for aid. The Global Fund has praised the announcement by the G8 to commit US$ 60 billion for disease control efforts. This may be a way for GFATM to reach its recently announced goal to become a $US 6-8 billion operation annually. Ironically, these efforts are criticized as inadequate. The BBC News reported Bob Geldorf as saying, “This wasn’t serious; this was a total farce… I won’t have it spun as anything else except a farce.” According to BBC, Geldorf added that instead of re-committing to the promises made two years ago, the G8 leaders had to get serious and deliver. Oxfam was reported to analyze that only “$3bn of the money was new.”

So the question remains – is global development and disease control aid helpful, inadequate or a hindrance? Aid can hinder entrepreneurship as was the case in Nigeria where one donor was working with local textile and pharmaceutical companies to develop net and insecticide bundled packages while other donors started importing LLINs for their programs. Can aid be more effective if there is donor coordination? Can aid succeed if it focuses on technology transfer and trade? Finally, does a performance based approach to aid as practiced by the GFATM really work and make bureaucracies deliver the goods and be accountable? If the answers to these questions are yes, there may be some hope for development aid.