Global Fund: The Uganda Challenge
How has the Global Fund operates in Uganda, its successes and challenges.
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First published: May 2, 2006
Many people by now know a thing or two about what has come to be known as the Global Fund. But what is this Global fund and how did things get to where they are today?
The successes and failures of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) are best understood in the context of Uganda, the country that pioneered the formation of the fund and also became the first to be implicated in the mismanagement of its money.
In 2001, Dr. Crispus Kiyonga, the then Uganda's Minister of Health participated in the writing of the constitution and modalities for operationalizing the fund, which was the world's first response to the health crisis particularly in Africa.
"Kiyonga was the Minister of Health some years ago and in that capacity he led in the creation of the Global Fund as the chair of the transitional working group, which wrote the constitution and the modalities for operationalising the fund," says Uganda's former Director of Health Service, Prof. Francis Omaswa.
In his submission to the Commission of Inquiry into the mismanagement of Global Fund money, Prof. Omaswa said that Kiyonga went on to become the first chairman of the board of the Global Fund while he (Omaswa) was a technical advisor.
Despite its efforts in the process of harnessing the Fund and the high profile officials in the program, Uganda became the first culprit to flout the rules of the fund, which call for high-level transparency. In August 2005, the Global Fund suspended all grants to Uganda after the country's Local Fund Agent discovered financial irregularities within the Ministry of Health's special Program Management Unit (PMU) that was running the project.
Representatives from the Fund described the disbursal suspension in Uganda as deeply regrettable, but insisted that such action was necessary to uphold the Fund's reputation as a transparent and fairly managed organization that works with rather than against the countries it supports.
The Uganda government was forced to disband the PMU and brought in the international accounting and auditing firm Ernst & Young to temporarily oversee grant administration, something that prompted the re-disbursement of the fund.
What is the Global Fund?
The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is an independent public-private partnership that was first proposed by UN Secretary-General, Kofi Annan, back in 2001, and officially came into being in 2002.
According to the Global Fund website www.globalfund.org, its aim is to raise funds and pool money from governments, businesses and individuals around the world, and channel it into programs to fight AIDS, TB and Malaria.
Around fifty countries have pledged money to the GFATM so far. Many of these are wealthy western or middle-eastern nations, although pledges have also been received from countries directly affected by AIDS, TB and Malaria. Uganda for example has pledged $2,000,000 to the Fund, while Burkina Faso has given $75,000. The biggest single donor country is the US, whose donations make up around 33% of the funds pledged every year.
Donor countries are expected to meet a proportion of this estimate dependent on their GDP, though pledges are essentially made on a 'goodwill' basis (with the obvious political kudos that this may bring). This allows the funding level estimates to be increased in the event of an emergency.
More recently, The Fund has also introduced a new system based on regular periodic replenishments to replace the previous 'ad hoc' method of donation. Three special 'replenishment conferences' were held in 2005 to introduce the system, which the Global Fund hopes will attract more future donors and enable more accurate forecasting of available resources over the coming years
The last of these conferences took place between 5th and 6th of September 2005 in London, England. Around 35 donor nations met to discuss funding for 2006 and 2007, and combined pledges for this period reached around $3.7 billion.
Contributions also come from large organisations (such as the International Olympic Committee and the Bill and Melinda Gates Foundation), from individuals (Kofi Annan has personally donated $100,000) and from fund raising events. A Real Madrid Soccer Match held in 2002 for example raised a grand total of $112,487 in one game alone.
Management of the system
Because the Fund wants to avert scandals like that that took place in Uganda, there is a complex system, which also pauses challenges to the implementation of the fund.
The amount of time that elapses between a grant being signed and the money getting where it is needed is too long since a special group called the Technical Review Panel (TRP) has to take time to review grant applications made by recipient countries.
The TRP, which is made up of an independent panel of health development experts who thoroughly examine the technical merits of every application have to also propose to the board that a grant application is approved without any conditions, that it is approved with conditions, that it is rewritten and resubmitted or that it is rejected altogether.
As a result, of the $990m worth of initial two-year grants approved in the first round of funding back in early 2002, only around two thirds were signed by recipient nations, and just $505m worth (just over half) had actually been distributed by the beginning of 2006.
Given that many of these grants are now coming up for renewal (and will only be renewed if countries can demonstrate good progress and distribution), such a time delay is not good news to many countries.
Moreover, to get funding from the GFATM, the recipient country must give assurance that the money given out in grants actually reaches the people who need it, the reason why every Principal Recipient is assigned a Local Fund Agent (LFA).
The LFA is an independent organization contracted by the Secretariat to administer and verify the correct distribution of funds, and provides an ongoing analysis of financial and overall progress. The LFAs include PricewaterhouseCoopers, Chemonics International and the United Nations Office for Project Services (UNOPS) as wells as Crown Agents.
According to the Global Fund management, the Fund ensures that to receive money, the government or even an individual organization make a grant application, which in theory means that funding is available to anyone that needs it. The only restriction is on the amount of money available in their central bank account.
An important part of any country's funding application process is the negotiations that take place with their Country Coordinating Mechanism (CCM). In every country that wishes to receive funding from the Global Fund, a CCM will be set up to help organize and submit grant applications to the Fund and monitor their implementation.
A CCM will generally be made up of a broad range of representatives from government agencies, NGOs (Non Governmental Organizations), local community and faith-based organizations, individuals working in the field and private sector institutions.
When the grant is approved and the money arrives, it is given to the Principal Recipient, which is basically the body that is legally responsible for distributing it or using it to tackle HIV, Malaria or TB in the country.
The Principle Recipient is often a government department or agency but it can be a local public or private organization, and many different Principle Recipients may exist within one country. In Uganda, we had the disbanded Program Management Unit (PMU) under the Ministry of Health.
However, the Global Fund money is supposed to be channelled exclusively outside of government intervention, through an NGO or a group of NGOs together to implement projects that the government is not directly involved with.
Uganda's Global Fund mismanagement scandal is one of the many challenges the Global fund is facing particularly in developing countries where the HIV/AIDS scourge remains a catastrophe and Tuberculosis as well as malaria continue to reap the countries of thousands of their population.
The Global Fund also has a challenge regarding the drugs that Global Fund money is being used to buy. The Global Fund specifies in its regulations that only drugs that have been pre-qualified by the WHO (World Health Organisation) can be used in treatment programs. But some people have been saying the WHO pre-qualification project is under-supported and has been slow to approve many HIV drugs, particularly the cheap generic drugs that are so vital to treating large numbers of people. For example, in 2005, several drugs were even removed from the WHO's list following problems with research methods. Some have since been reinstated, but the process for reassessment is slow.
Because the number of drugs available to Global Fund treatment projects is currently limited, only an estimated 220,000 people are currently on ARV drugs as a direct result of Global Fund money.
Successes of the fund
Despite the problems, Global Fund money has produced many practical and positive results, and seems to be one of few international health initiatives that are actually achieving its goals.
A recent review of progress found that the Fund had exceeded 7 out of 8 of its major targets for 2005. These included the provision of care and support for 66% more AIDS orphans than expected, ACT Malaria treatment for 56% more people than planned, and 220,000 people put on antiretroviral drugs.
Other progress include the training of healthcare professionals, the provision of insecticide treated mosquito nets, the modernization and conversion of labs and healthcare centers and the rapid expansion of the DOTS TB treatment strategy in dozens of different countries.
All these successes put aside, for now the focus is on whether and how much of these are being received by the intended beneficiaries and how long it may take given the performance of some beneficiaries implementers like the PMU of Uganda.
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First published: May 2, 2006
Gideon Munaabi is a journalist and public relations practitioner with Ultimate Media Consult (U) Ltd. He has been and continues writing widely for different publication locally and internationally. He is a founding member of Ultimate Media Consult (U) Ltd and is currently the chairman of the organisation.