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Confusion over Shs1.4 trillion Global Fund money

By Flavia Nassaka

Donor audit report exposes Health officials, frustrated boss offers to resign

Uganda is once again the centre of attention over the mismanagement of resources provided by the Global Fund to fight HIV, malaria, and tuberculosis. The trouble this time appears to be around the model adopted by Global Fund to manage the resources. Unconfirmed reports say that Dr. Vinand Nantulya, the Uganda AIDS Commission chairman, has been battling to resolve the crisis but has thrown in the towel. Nantulya, who doubles as chairman of the Global Fund Country Coordinating Mechanism (CCM), a board that oversees how the donor money is being used has reportedly tendered in his resignation to the appointing authority.

When contacted by The Independent, Nantulya confirmed his wish to resign, but refused to say why. In late 2015, a team from the GF headquarters in Geneva met officials responsible for implementing the grants but failed to resolve the crisis.

The grant at stake is $421 million (Approx. Shs1.4 trillion) signed in 2015. It includes initial grants worth US$226 million comprising US$176 million for HIV, US$14 million for strengthening health systems, US$22 million for tuberculosis, and $14 million for malaria.

It was anticipated that ARVs coverage will increase to 69% of people living with HIV by 2017, prevention of Mother-to-Child Transmission of HIV will be increased from 85% to 90% by end of 2016, and people with TB tested for HIV and ART given to the co-infected.

So far, experts say, there’s no visible evidence that the grant is fulfilling its purpose. Only half of the 1.5 million who need HIV treatment get it and people in the 10 most affected districts by malaria are still grappling with the disease.

The Ministry of Health has sought to clear itself of blame. It says it received only 5% in cash as the new model means the Fund uses the rest to procure the required commodities itself and distribution is done by private and public entities.

But following several reports of drug shortages and failure to absorb allocated resources, the GF Office of the Inspector General (OIG) carried out an investigation on whether the national supply chain delivers quality medicine, in a timely manner, and whether there’s accurate data to support decision making on efficient use of the donor resources.

Results of the audit released on Feb.26 have caused shock waves in the health sector.

The audit team found that of all money released by the Fund between January 2013 and June 2015, only 46% had been spent. Meanwhile, 70% of the 50 health facilities visited by the investigators lacked at least one essential medicine with HIV being the most affected.

Malaria drugs and test kits were also out of stock in 68% of the facilities and 64% reported lack of tuberculosis drugs. In some of the facilities grappling with drug shortages, the health officials also found tomes of accumulated expired medicines. This happened in 54% of all the visited facilities.

It was also found that medicines procured at the country level were 36% more expensive than internationally benchmarked prices.

Dennis Odwe, the Director, Action Group for Health and Human Rights and HIV/Aids (AGHA) Uganda told The Independent that HIV drugs are procured through national systems by the National Medical Stores at higher prices to support local industries. He said the high cost means fewer drugs are bought for the same money. He said the approach is wrong.

“They want to support local industry but this support shouldn’t come at the expense of access and accountability,” he said.

Under Global Fund procedures, once a country shows no progress in using its resources, the money is withdrawn and given to countries that can utilise it better.

Over 700,000 million Ugandans enrolled on free government provided HIV drugs could lose them if GF withdrawals its support. The HIV patients who cannot afford to pay for drugs risk developing drug resistant strains and death.

Uganda depends largely on donor money to fund its programmes to curb HIV/AIDS, malaria and tuberculosis. In addition to meeting other health needs, only 5% of the national budget goes to the Ministry of Health contrary to the recommended 15% by the benchmark Abuja Declaration.

This is the third time that the GF project in Uganda is coming under threat since 2002 when Uganda started receiving this aid which is valued in a billion dollars of grants so far signed.

In 2005 the money was briefly suspended after an audit revealed graft that sacked in then-Health Minister Jim Muhwezi and his deputies Dr. Alex Kamugisha and Mike Mukula.

Two years later, in 2007, the Global Fund again withheld $16 million on grounds of poor performance and misappropriation of money.

Tough recommendations

The Ministry of Health, which is the principal recipient of the money, is being blamed for the mess. The GF audit team says the Ministry lacks the necessary statistics for planning and has recommended that efforts are made to establish the exact number of people who need treatment. This will partly provide a window into tackling the issues of stock-outs in clinics and expiry of the same unused drugs in others.

Meanwhile, Civil Society Organisations in the health sector want the Ministry of Health kicked out managing the GF activities. They have recommend instead that implementation be handed to a body with a proven track record of successful grant management, like The AIDS Support Organisation (TASO).

Started by now renowned HIV/AIDS activist, Noereen Kaleeba and her husband, Christopher Kaleeba in 1987 at Mulago Hospital where they worked, TASO grew to be one of the leading support organisations for people living with HIV/AIDS. TASO already manages part of the GF grant – $7.8 million which it uses to ensure provide HIV/AIDS sensitisation on harmful gender-based and socially discriminatory practices hindering access to health services by vulnerable groups.

There is also a demand for officials in charge of overseeing the funds to resign. Lillian Mworeko of the International Community of Women Living with HIV Eastern Africa (ICWEA) says they should resign because it is clear that nothing has changed despite receiving several warnings from the Fund.

Ministry explains

The report did not specify the exact amount of money that has been lost so far and who is responsible for the loss.

Ministry of Health Spokesperson Rukia Nakamatte that since the Global Fund changed its model from offering cash to procuring commodities worth that money, the ministry manages only 5% of the grant. She said they have already used 48% of the money availed to them and by 2017/2018 when it expires, there will be something to show for it.

Her view was shared by Dr. Jim Arinaitwe, the Coordinator of Grants at the ministry. In an earlier interview with The Independent, he said the stock-outs happened in the country because commodities provided for the first and second quarters were not enough because of unanticipated disease outbreaks and the World Health organization (WHO) recommendation to enroll more people on HIV drugs. He denied drugs were misused.

“The HIV grant, for instance, is supposed to be used within a period of three years but because of increased consumption, all commodities for year one have been consumed. We have even front-loaded commodities for year two into year one,” he told The Independent adding that they did the same for malaria drugs when severe malaria broke out in Northern Uganda.  Global Fund is set to spend $13 billion on African countries in 2016 which is $2 billion less than what they set in 2015.

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