AfricaDiasporaHealthHealth PolicyNigeria

The Global Fund, Governance and the Shame of a Country

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Gloria is a vibrant young lady who is “living positively” with HIV. She featured on our #OpenMoH radio show five months ago and shared with us the difficulties faced by people living with HIV (PLHIV) in accessing their life-saving antiretrovirals (ARVs). At that point there was a drug stock-out at most health facilities where PLHIVs usually access their drugs. In a country where 100% of those on ARVs are funded by donor funds, either by PEPFAR or the Global Fund, we are faced with the incredibly sad situation in Nigeria where we have been found incapable of properly utilizing resources given to us to fund the treatment and care of diseases that we should be managing by ourselves. After the recent scandal in the mismanagement of GAVI funds, once again Nigeria’s reputation is being torn to shreds in the international community by events in our health sector.

Since 2003, the Global Fund (GF) has invested above US$1.4 billion in Nigeria. These investments represent the GF’s largest portfolio. It is not surprising that the GF is spending so much in Nigeria, as we have 24% of the global disease burden of malaria, the largest in the world, 9% of the HIV disease burden, the second-largest; and 7% of the TB burden, also the second-largest.

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After rumours had been circulating for weeks, on May 3, 2016, an audit by the Office of the Inspector General (OIG) was finally made public. It concluded that Nigeria’s procurement and supply chain management, financial management, and program management were ineffective. Specifically, it found that The National Agency for Control of AIDS (NACA) and the National Malaria Elimination Program (NMEP) do not monitor the delivery of health products and found “discrepancies” of $3.7 million and $0.5 million for medicines ordered through pooled procurement and received in the central medical store in Lagos. The OIG identified a further US$20 million paid by NACA to an international procurement agent without any confirmation that the goods were received. Most tragically, the audit also found significant weaknesses in supply chain management that led to stock outs of anti-retrovirals and artemisinin-based combination medicines in all 42 high volume health facilities – in some cases for up to eight months.

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To understand the findings of the audit, you have to understand the workings of the Global Fund and its governance structure. Unlike most other donor organisations, the Global Fund has almost no human resources in the countries where it works. It funds projects through existing government or non-governmental organisations, which are organised in chains of primary and sub-recipients. In every country, there is a “Country Coordinating Mechanism”  (CCM) to encourage local ownership and participatory decision-making. One of the key functions of the CCM is to oversee progress during implementation. In Nigeria, for three years under the Jonathan era, there was a perverse arrangement where the leader of the CCM was also the Minister of Health in Nigeria, still on the website when accessed on 21/05/16.

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Since The Global Fund does not have local staff, to oversee the financial propriety of recipients of Global Fund funds, a “Local Funding Agent (LFA)” is appointed in each country. It so happens that the “Local” Funding Agent for Nigeria is actually in Ghana; PriceWaterhouseCoopers (Ghana) Ltd. They would be the primary originators of most of the findings that were subsequently escalated to the Office of the Inspector General (OIG). The OIG is itself independent of the Global Fund Secretariat and reports directly to the Board through its Audit and Ethics Committee.

In addition to the audit published, the OIG on the same day reported on their findings on a specific investigation into activities of a sub-recipient to NACA; the Department of Health Planning, Research and Statistics (DPRS) of the Nigerian Ministry of Health. Investigations revealed a disturbing web of impunity, forgery, failure of oversight and a lack of leadership.

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Reading through the report is an extremely painful experience. The discovery by the Global Fund of evidence of systematic embezzlement, fraudulent practices, and collusion, is a great disservice to donors and development workers who put in their best to ensure improved health outcomes in Nigeria. Most tragically – it is a betrayal to the people that health workers have vowed to serve- our patients. With Nigeria depending so heavily on donor funds for HIV prevention, treatment, and care, it is our collective responsibility to ensure such funds are used with the utmost prudence. This has not been the case here.

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The Opportunity cost of this fraud is monumental. The OIG report concluded that expenditure of US$3,816,766 was not in compliance with the grant agreement. A 2014 PEPFAR report showed that it cost US$315 to treat one person living with HIV annually (this could be less in 2016). Based on the same report, for every 1,000 persons supported on ARV treatment for one year, PEPFAR estimated that 449 children are prevented from becoming orphans. Using the 2014 PEPFAR estimates, the amount embezzled by DPRS staff would pay for the annual treatment of 12,000 PLHIVs and prevent 5,400 children from becoming orphans in one year.

At Nigeria Health Watch, we wholeheartedly support the efforts of the Economic and Final Crimes Commission’s (EFCC) investigation into this matter. In the public statements of the leaders of the organisations involved, we have noticed the defensiveness in tone. They are reported to have called for an “independent review” of the OIG audit and requested the “convening of a national forum to fashion out a system of grant/donor relationship that is based on mutual respect to ensure national pride”. There is no better way to protect our national pride than taking their oversight and governance responsibilities as a matter of national responsibility.

We expect the leadership, through the chain of command of the organisations involved and the several governance layers to take full responsibility and be bold to say that never again will our patients be betrayed in this way. From the Minister of Health’s twitter handle, we understand that two committees have been set up to look into the matter and report back in four weeks. Two weeks have gone past since the announcement on May 9. We are counting down.

In the long term, we call on the government of Nigeria to take responsibility in procuring ARVs for people living with HIV in Nigeria. South Africa has the largest ARVs programme globally which is being funded from domestic resources. In contrast, Nigeria, which has the largest GDP on the African continent, depends on donor funds to provide life-saving drugs for its people. This should not be the case. We are glad that civil society is coming together to insist that enough is enough…

A Press Conference by the Coalition of Fund the Fund Campaign has called on Nigeria to ensure better management of Global Fund funds.

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As President Buhari aptly says, “If we don’t kill corruption, corruption will kill us”. Sadly, it is killing us already.

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