Uganda was the darling of hte international public health community some 15-20 years ago when it tackled the HIV/AIDS epidemic head on with local initiative, both by government and civil society. Today in the era of huge disease control grants Uganda is not doing so well. In August 2005 problems within the Project Management Unit within the Ministry of Health that oversaw all Global Fund grants implementation led to a suspension of all grants. This was a major set back for the Round 2 Malaria Grant, which had started in March 2004. The suspension led to serious drug shortages for the three disease programs.
Although a recently published progress report at the Global Fund shows that grants where government agencies are the principal recipient perform more poorly than those managed by NGOs, the Uganda experience was an extreme event. It appears that the country may not have fully recovered from the problems.
A headline in the Monitor newspaper of 11th July 2007 read, “Shs3.7 Billion Malaria, ARV Drugs Rot in National Medical Stores” (about $US 2.3 million). According to the article, a team of MPs “were shocked to find eight containers of 2-feet, full of expired drugs yet Ugandans are perishing in hospitals without treatment.” These included both ARVs and antimalarial drugs. It was reported that most of these drugs did not ‘belong’ to the National Medical Stores (NMS) but to donor programs. This may point to a deeper problem: the NMS should be part of the management process for these donor programs, not just a passive depository for supplies.
The General Manager of the NMS complained that, “Many of the programmes procure short-lived drugs and leave them for a long time at NMS, which in many cases expire.” The reality is that the current first line antimalarial drugs, artemisinin-based combination therapies (ACTs), have a short shelf life. As seen in the attached picture of a packet of antesunate-amodiaquine, ACTs typically expire two years from manufacture. This means that national malaria programs must forecast, procure and manage ACTs in such a way as to guarantee prompt use of supplies.
This news speaks poorly for the malaria grants in Uganda. The Global Fund publishes report cards and score cards on all grants, and one can easily find these on each country’s page at the Global Fund Website. The most recent progress report for Uganda’s Round 2 malaria grant is November 2006. That progress report noted that, “Performance has been poor because of the loss of momentum due to the suspension of GF grants in Uganda for a period 2.5 months, as well as the disbandment of the Project Management Unit (PMU)” and that implementation was behind schedule.
Concerning procurement, the report stated that, “On lifting the suspension, an aide memoir was signed at which certain actions were agreed upon to be achieved by the PR and CCM. This included the recruitment of a Third Party procurement agent and the revision of work plans and procurement plans to take account of the delays due to the suspension. To date, a procurement agent has not been appointed.”
More specifically, the New Vision newspaper of 11 March 2007 reported that, “The Global Fund has permanently terminated two grants to Uganda for malaria and tuberculosis because of what it called “unsatisfactory performance.” As a result, Uganda has missed about $16 million,” of which $14.7 million was for malaria. The Round 4 malaria grant, which started in December 2005, after the problems of suspension had been resolved, remains. There is hope, as the most recent progress report for this grant, issued in January 2007, indicates that WHO is helping address procurement problems. The report states that, “This grant is achieving its targets, with the first tranche of ACTs having been purchased by WHO. Despite the setback of GF grants in Uganda due to the suspension, this grant, which is largely procurement-dependent, is moving ahead with the support of WHO.”
While we cannot change the shelf life of ACTs, we can improve procurement and supply management of malaria drugs. Although the Global Fund has canceled few grants, it is not unwilling to take action. Ideally RBM partners should step up and provide technical assistance to help grant performance long before the grant cancellation question arises.