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.
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.
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.
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.
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.
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.
As President Buhari aptly says, “If we don’t kill corruption, corruption will kill us”. Sadly, it is killing us already.
EFCC should conduct a thorough investigation and the government of Nigeria must ensure those found guilty are severely punished to serve as a deter-ant to others. when I was actively involved in HIV programming, the stories about NACA were never good. I expected that they would have changed by now.
Very unfortunate. This can also lead to resistance strains as people living with HIV can’t have access to this life saving drugs.
It is so sad when we hear of these ill menace happening with development funds.Especially these of us who call them selves professionals, but are not leaving to the calling and dictate of the Accounting profession. No technical staff will commit or perpetrate such act, it MUST be with connivance of corrupt and dubious finance staff. My hope is, Global fund will ensure 80% is spent on recruiting credible staff for its intervention in the future, than relying of few individuals who pretend to be saints, but turn out to become monsters. Not all NGOs are truly NGOs.
Finance Manager (MCSP)-JSI Nigeria
This captivating write up is not only rich with useful information, it is also adequately propped to influence critical stakeholders. It needs to go beyond the present reach- newspapers, magazine, etc- to achieve the right objectives.
Surely we all know that this has been the ‘fate’ of development, loan and Grant funds in all aspects of Nigeria’s public life since time immemorial and happens to many University Research Grants as well asin the Civil Society.
You see many of us Nigerians, especially in positions of ‘authority and responsibility’ do not yet appreciate life or seek to increase the quality and quantity of that life among our people. Their actions are seldom about the human, only about the money.
Because they do not see the patients dying in their executive offices or groaning during their conferences in Nicon Nuga, such ‘big big’ officials only see money, They never see that Fellow Nigerians die horrible deaths whenever those responsible for their medication, safety, security, education, road networks and medical care abandon their role and prefer to steal. Of course some of it is Incompetence but most of it is greed unrestrained greed.
Usually only the medical personnel and individual families see the pain, suffering and blood and bodies. But often medical personnel are involved in the corruption.
Why are we not ashamed? Why should we have to grovel and go begging and depend on international funding to solve our simple medical needs, even mosquito nets and media adverts to ‘save Nigerians, not foreigners? We go to other countries or businesses who give from their prudent management of funds. When will we take responsibility for our citizens’ lives?
If you think this medical scandal is a big and monumental disgrace to the Nigerian medical sector please also add the cost of the politically organised Okada Epidemic which has cost billions locally, killed more and made more orphans than HIVAIDS will ever accomplish. Every single Nigerian has seen, been involved in or has a family member who has been injured by an Okada -an Un acknowledged Epidemic by any name.
The millions of potholes on the road also kill and medicine is silent. Perhaps we expect the Global Fund to fill them for us?
The probes are welcome and coming from President Buhari, we pray they will yield fruit. but the probes will not solve the systemic problems in medical administration. Remember this Nigeria is the country where opiates were banned for years causing torture to hundreds of thousands of post operation patients and radio-isotopes were placed out of the reach of teaching hospitals trying to treat thousands of cancer patients and house-jobs can take 3 years to find.
Why do we as a country shoot ourselves in the foot before every race? The answer is a lack of love of humanity in many who require it as part of the job, and not to be discarded on assumption of office. Academic qualifications may get you a job, but your heart will determine if you become a ‘Thief in Office’ or a servant of the citizen.
Dr Tony Marinho tonymarinho.com Educare Trust
Quite an explicit article, sometimes I bad we can’t do things right for once. Global Fund and other donor agencies should do more to monitor how their monies are spent, I understand they want local ownership but when it comes to money, an eagle eye must be activated.
I was devastated by the news when I initially read about it. I live and work in a rural community and I know the situation with access to treatment.
I had the opportunity to implement a Community System Strengthening Project for ATM services. I worked with six global fund supported facilities for a period of five months.
When I reported some of my findings to the agency in charge of supervision at the state level, she made no attempt to correct the anomaly.
I am very disturbed because the maximal effect is felt by us young people and women at the grassroots. The implications are grave.
I sincerely wish that beyond punishing those involved in this particular case, a more thorough M&E process is put in place at State and Local levels. We need to focus on logistics chain management.