The Politics of the Global Fund in Uganda

By Esther Nakkazi

Five months ago officials from the Global Fund came to Uganda and at a press conference at the media centre, announced the disbursement of $4.2 million the next month, to avert a treatment crisis in the country at the time.
To date the money has never been disbursed and Uganda has failed to qualify for Round 9 of the Global Fund causing a $20 million funding gap in HIV and early deaths due to treatment interruptions.
HIV/AIDS financing delays and cuts by development partners are now causing rationing of anti-retroviral drugs and most medical institutions are turning away new patients, unable to enroll them for the life-prolonging drugs. The latest has been a cut from the US President Emergency Plan for AIDS Relief (PEPFAR) funding for paediatric HIV, which will cut at least $1million next year.
Prof Addy Kekitiinwa the executive director Baylor Uganda Children’s Foundation during the annual paediatric conference said – ‘As I speak now, I have a letter from PEPFAR asking me to stop enrolling children. Even if all factors remain constant we still need the government to help or we shall not achieve universal access.
Starting April next year PEPFAR the biggest funder of HIV programmes in Uganda will cut up to $1million from the $7million annual contribution it was making to the paediatric HIV programme. Also the Global Fund money although available is not yet accessible.
Officials from the ministry of Health say that the Global Fund money has been disbursed from New York to Uganda’s central bank account, but there are administrative problems that are hindering its use.
Dr. Francis Runumi the commissioner Planning and Development at the ministry of Health says although the money is on the account but the Global Fund at first disbursed it to the wrong account and later when the signatory to that account was changed, it caused a further delay. In the meantime patients are dying due to ARV stock outs.
The signatory to the account at the central bank was Mary Nannono, the former permanent secretary in the ministry of Health who was interdicted and replaced by Dr. Sam Zaramba acting in the position.
Officials from the ministry of Health who want to keep this out of the media say, they thought it would be automatic for the process to accept a new signatory but as it turned out, due to the high sensitivity by the bank, a lot of technicalities need to be dealt with before the unanticipated long delay is sorted out.

Does the Global Fund have Bad Will for Uganda?
The $4.2 million, which was supposed to be a stopgap measure, in March 2009 is now expected to be disbursed early 2010. But in this entire saga, some officials accuse the Global Fund of having bad will for Uganda.
They say this could be due to the strained relationship, which was created when in 2005, serious mismanagement of $1.6 million was discovered leading to the suspension of financing to Uganda.
However, other sources attribute Uganda’s problems with the Global Fund, to its failure to change its management system. While the Global Fund insists that Uganda should change and operate under the project mode, the government still wants the money to go into budget support.
But Ugandan officials say that even if the Global Fund does not say it explicitly they do not want their money to go to budget support. They want Uganda to go into project mode where they can monitor money, can have a say about the expenditure and most importantly where the Global Fund prominence is proclaimed.
Some say it has a stereotyped way of working, which is too limited in its approach. For instance when Uganda mismanaged only $1.6million they rushed to arrest the culprits, that was not bad at all given the corruption in Uganda but again there was no mechanism for redress.
According to records, at least 70 percent of the people who had not accounted for the funds have already been cleared, recovering at least $1 million from institutions and individuals implicated in the misappropriation.
But even then the funds that could be assessed in Round 7 and Round 3 are not yet available although the two parties had earlier this year committed to resolve all outstanding issues so that the intended beneficiaries are not affected.
The weaknesses that the two sides had were identified and rectified. We shall ensure that the bad past is left behind, said Dr. Richard Nduhura the state minister for Health during a Press conference held to announce the stop gap measure earlier in the year.
This signified a renewed commitment from the Uganda Government to address past weaknesses and strengthen health systems in the long term.
But ministry of health officials say that all other conditions that were required by Uganda like improvement of the procurement and supply chain and a third party agent have now been fullfilled. But there is no money yet.
“If we could access the $254 million for the two rounds, it would be enough to take us through the next two years. We have lost Round 9 but it was rated fit for resubmission,” said Jim Arinaitwe the Global Fund coordinator at Uganda Aids Commission (UAC).
The country deliberately missed out on Round 8 of the Global Fund last year but had approval for two proposals under round 3 and 7, which were supposed to provide enough funds for running HIV programmes. But funds did not come in on time, which has in the long run affected treatment programmes.
The Global Fund has pumped nearly $52 billion in fighting the ravages of the HIV pandemic. Over the next year, the Global Fund will be another $2 billion short to meet its goals for funding new programmes.
To Uganda health officials the Global Fund remains an enigma -on one hand there is a lot of flexible but on the other hand there is no flexibility. It says something can be done but when it is suggested and presented on paper it is denied!