Halt of Global Fund may be a blesssing
Sep 08, 2005
UGANDA'S mismanagement of the Global Fund (GF), was merely a symptom. We need to look for the causes which are rooted in the Fund’s concept and design.
By Sam Okuonzi
UGANDA'S mismanagement of the Global Fund (GF), was merely a symptom. We need to look for the causes which are rooted in the Fund’s concept and design.
Health leaders at the GF headquarters in Geneva and those in Uganda need to reassess the entire GF strategy. The idea of the Fund is persuasive. AIDS, TB and Malaria account for most of the disease burden in poor countries, such as Uganda.
The fund is expected to be different from other types of aid, which are largely regarded as bad aid. A recent study on the quality of external aid has identified four factors that make aid bad. These are:
Tying aid to ideological, bureaucratic and profit oriented conditions
Large, inefficient administrative structures taking more than 10% of the budget;
Uninformed or ill-prepared and non-participating or inadequately participating beneficiaries
The use of project approach in administering aid, and in particular, where within the project there is a proliferation of grants or sub-projects.
Lamentably, the GF in general, and that in Uganda fail miserably on the aid quality index, as it currently conforms to these bad characteristics of aid.
What was initially persuasive about the GF was that the fund would be demand-driven, meaning the country would propose how to use the money to tackle the diseases. It would be used on an inclusive partnership basis. The partners would include both government and non-government stakeholders.
The fund was to be performance-based, whereby money would only be given again to a user if the previous money had produced clear and positive results in relation to the three diseases. It would strengthen the coordination of all funds including other aid initiatives targeting the three diseases. And the fund would be additional to the Government’s usual health budget.
So far we have failed on all accounts. To be pragmatic, a country needs to assess the prospects of such charity on an annual basis.
Moreover, short-term project-based attempts to address fundamental problems underlying diseases have often failed. Enthusiasts claim that such a fund can spearhead and spur development of a comprehensive health care system on the back of a successful disease control and economic development and poverty alleviation. There is, however, no evidence that short-term and narrowly targeted aid has caused this kind of development in any poor country.
In fact, when such an aid ends, it becomes unsustainable by the recipient country. The GF’s architects and governments of poor nations saw it as free money that should not be missed, its limitations notwithstanding.
In addition to this conceptual flaw in the GF, its implementation has already undermined one of its key principles.
Uganda submitted an omnibus proposal for all three diseases in round-one proposals. This was rejected by the GF headquarters in Geneva in favour of three separate, disease-based proposals.
An omnibus proposal was closer to strengthening the whole health system. The omnibus proposal would be more efficient through a transparent oversight of allocating and sharing of overhead costs.
In Uganda, the GF and similar initiatives such as PEPFAR have proved to be disruptive rather than complementary to national efforts to build a viable health system. There is a national consensus that the best way to build the health system is through the budget system, where funds are dispersed by the Ministry of Finance.
It is not a perfect system, but there is increasing evidence that more money released by the Ministry of Finance reaches the intended beneficiaries. It is more transparent and major cases of mismanagement can be discovered and rectified timely.
Because of the project nature of GF, there has been an unfortunate jostling for its control by the Ministry of Health and the Uganda AIDS Commission (UAC). UAC operates on the National AIDS Coordination principles of 3-ones, where a country is supposed to have one agreed AIDS plan, one coordinating body and one monitoring system.
But the GF project introduced separate and parallel arrangements. The budget-support approach of the GF would not warrant the creation of such parallel arrangements.
Crucially, the creation of the Project Management Unit (PMU) was also a result of an internal contradiction in the Government.
On the one hand, the Ministry of Health, arguing that the health sector is grossly under-funded was desperate to use the GF to mobilise more funds for the health sector. Experts have projected that unless Uganda increases Government health spending from around $10 to $40 per capita per year, it will not achieve its Millennium Development Goals (MDGs).
On the other hand, the Ministry of Finance insists that it has set health expenditure ceilings, which it deems ‘sacrosanct.’ If the GF brings more funds into the country, the health budget will be cut down proportionally. In effect, the GF would be useless to the health sector and to the cause of the 3 diseases. Pushed against the wall, one can imagine, the MoH had to opt for a project for the GF where there would be some protection of both GF and the health budget.
The key problem of Uganda’s GF was its poor oversight and coordination. The Country Coordinating Mechanism (CCM), renamed National Coordination Committee (NCC) has been ineffective.
Through the establishment of the PMU, the MoH and Ministry of Finance lost a close oversight of the fund. The CCM is viewed by observers as overlapping with UAC. NGOs claim that the CCM is dominated by the Government which has taken the chair, co-chair and secretary of the committee.
Representation of different institutions is said to be undermined by inadequate communication to members and by the perception that members represent personal rather than group interests.
CCM meetings are infrequent and there is a lingering perception that important decisions are taken outside the CCM and only brought to the CCM for endorsement. There is concern that CCM is dominated by AIDS activists and that TB and malaria lack appropriate voice and expertise.
Districts and implementing NGOs have not been adequately sensitised. Also, districts prepare separate GF plans, in addition to the annual district plans. This is unnecessary double work.
Accounting requirements are cumbersome and do not necessarily produce the desired results. Demanding documented evidence of expenditures such as on transport or meals in local eating places can force people to forge receipts since such services are not routinely receipted. Accounting and reporting need to be simplified and tied to audited outputs related to the three diseases.
The suspension of the GF to Uganda could therefore be a blessing in disguise. It provides an opportunity to review the GF concept, with a view to strengthening the health systems as a whole.
Appropriate emphasis on the three diseases could be given only where the system is weak in providing specific aspects of support in relation to these diseases. The GF should be fitted within the institutional structures of the country. The fund should be channeled through the country’s budget support system.
The writer is the Secretary General National Council for Children and a Health Policy Consultant
UGANDA'S mismanagement of the Global Fund (GF), was merely a symptom. We need to look for the causes which are rooted in the Fund’s concept and design.
Health leaders at the GF headquarters in Geneva and those in Uganda need to reassess the entire GF strategy. The idea of the Fund is persuasive. AIDS, TB and Malaria account for most of the disease burden in poor countries, such as Uganda.
The fund is expected to be different from other types of aid, which are largely regarded as bad aid. A recent study on the quality of external aid has identified four factors that make aid bad. These are:
Lamentably, the GF in general, and that in Uganda fail miserably on the aid quality index, as it currently conforms to these bad characteristics of aid.
What was initially persuasive about the GF was that the fund would be demand-driven, meaning the country would propose how to use the money to tackle the diseases. It would be used on an inclusive partnership basis. The partners would include both government and non-government stakeholders.
The fund was to be performance-based, whereby money would only be given again to a user if the previous money had produced clear and positive results in relation to the three diseases. It would strengthen the coordination of all funds including other aid initiatives targeting the three diseases. And the fund would be additional to the Government’s usual health budget.
So far we have failed on all accounts. To be pragmatic, a country needs to assess the prospects of such charity on an annual basis.
Moreover, short-term project-based attempts to address fundamental problems underlying diseases have often failed. Enthusiasts claim that such a fund can spearhead and spur development of a comprehensive health care system on the back of a successful disease control and economic development and poverty alleviation. There is, however, no evidence that short-term and narrowly targeted aid has caused this kind of development in any poor country.
In fact, when such an aid ends, it becomes unsustainable by the recipient country. The GF’s architects and governments of poor nations saw it as free money that should not be missed, its limitations notwithstanding.
In addition to this conceptual flaw in the GF, its implementation has already undermined one of its key principles.
Uganda submitted an omnibus proposal for all three diseases in round-one proposals. This was rejected by the GF headquarters in Geneva in favour of three separate, disease-based proposals.
An omnibus proposal was closer to strengthening the whole health system. The omnibus proposal would be more efficient through a transparent oversight of allocating and sharing of overhead costs.
In Uganda, the GF and similar initiatives such as PEPFAR have proved to be disruptive rather than complementary to national efforts to build a viable health system. There is a national consensus that the best way to build the health system is through the budget system, where funds are dispersed by the Ministry of Finance.
It is not a perfect system, but there is increasing evidence that more money released by the Ministry of Finance reaches the intended beneficiaries. It is more transparent and major cases of mismanagement can be discovered and rectified timely.
Because of the project nature of GF, there has been an unfortunate jostling for its control by the Ministry of Health and the Uganda AIDS Commission (UAC). UAC operates on the National AIDS Coordination principles of 3-ones, where a country is supposed to have one agreed AIDS plan, one coordinating body and one monitoring system.
But the GF project introduced separate and parallel arrangements. The budget-support approach of the GF would not warrant the creation of such parallel arrangements.
Crucially, the creation of the Project Management Unit (PMU) was also a result of an internal contradiction in the Government.
On the one hand, the Ministry of Health, arguing that the health sector is grossly under-funded was desperate to use the GF to mobilise more funds for the health sector. Experts have projected that unless Uganda increases Government health spending from around $10 to $40 per capita per year, it will not achieve its Millennium Development Goals (MDGs).
On the other hand, the Ministry of Finance insists that it has set health expenditure ceilings, which it deems ‘sacrosanct.’ If the GF brings more funds into the country, the health budget will be cut down proportionally. In effect, the GF would be useless to the health sector and to the cause of the 3 diseases. Pushed against the wall, one can imagine, the MoH had to opt for a project for the GF where there would be some protection of both GF and the health budget.
The key problem of Uganda’s GF was its poor oversight and coordination. The Country Coordinating Mechanism (CCM), renamed National Coordination Committee (NCC) has been ineffective.
Through the establishment of the PMU, the MoH and Ministry of Finance lost a close oversight of the fund. The CCM is viewed by observers as overlapping with UAC. NGOs claim that the CCM is dominated by the Government which has taken the chair, co-chair and secretary of the committee.
Representation of different institutions is said to be undermined by inadequate communication to members and by the perception that members represent personal rather than group interests.
CCM meetings are infrequent and there is a lingering perception that important decisions are taken outside the CCM and only brought to the CCM for endorsement. There is concern that CCM is dominated by AIDS activists and that TB and malaria lack appropriate voice and expertise.
Districts and implementing NGOs have not been adequately sensitised. Also, districts prepare separate GF plans, in addition to the annual district plans. This is unnecessary double work.
Accounting requirements are cumbersome and do not necessarily produce the desired results. Demanding documented evidence of expenditures such as on transport or meals in local eating places can force people to forge receipts since such services are not routinely receipted. Accounting and reporting need to be simplified and tied to audited outputs related to the three diseases.
The suspension of the GF to Uganda could therefore be a blessing in disguise. It provides an opportunity to review the GF concept, with a view to strengthening the health systems as a whole.
Appropriate emphasis on the three diseases could be given only where the system is weak in providing specific aspects of support in relation to these diseases. The GF should be fitted within the institutional structures of the country. The fund should be channeled through the country’s budget support system.
The writer is the Secretary General National Council for Children and a Health Policy Consultant