14 March 2011 (PlusNews) – When the Global Fund to fight AIDS, Tuberculosis and Malaria suspended funding to Zambia in late 2010 it made international headlines and rocked donor confidence, but the stock-outs and drug rationing in the wake of the scandal have received little attention.
In March 2009 a whistle blower’s allegations of corruption in the Zambian Ministry of Health (MoH) triggered an investigation by the auditor general, and a web of corruption in the health sector began to unravel. The audit found that the largely donor-funded ministry could not account for more than US$7.2 million, about five percent of which was estimated to have come from Global Fund coffers. It was just the tip of the iceberg.
A separate Global Fund audit painted a disturbing picture of poor financial management across the four principal recipient organizations: the ministries of health and finance, the Christian Health Association of Zambia (CHAZ) and the Zambian National AIDS Network.
Principal recipients receive Global Fund financing directly for programme implementation or to pass on to other organizations called sub-recipients. The Global Fund subsequently suspended grants to all these organizations except CHAZ, and stripped the MoH of its principal recipient status, giving this responsibility to the Zambia country office of the United Nations Development Programme (UNDP). Resolving the problem brought delays in funding distributions and stock-outs of antiretroviral (ARV) and tuberculosis (TB) drugs for treating this common co-infection.
The UN Children’s Fund (UNICEF) and internationally funded initiatives like the USAID DELIVER PROJECT scrambled to bring in emergency supplies. Missing money, missing drugs Activists said that by November 2010, ARV and TB drug stock-outs were being widely experienced. Lynn Tamba, TB programme officer at CHAZ, which provides treatment for both infections, described the stock-outs as a crisis, and said the organization had run out of alternative sources for these drugs two months into the shortages. Paul Kasonkomona, the focal point for Oxfam’s Civil Society Health Forum, which works closely with the Treatment Action Literacy Campaign (TALC), said other HIV organizations were also receiving reports of stock-outs in the capital, Lusaka, as well as Copperbelt Province on the northern border with the Democratic Republic of Congo, and other areas.
The stock-outs eased in early 2011, but Kasonkomona said TALC had documented at least 14 deaths directly linked to the unavailability of TB drugs. Walter Proper, country director of the USAID DELIVER PROJECT and the US-funded Supply Chain Management Systems (SCMS) project, said the stock-outs in early November were driven by a variety causes, including administrative delays in signing the contracts that would allow Global Fund money to be channelled through UNDP instead of the MoH.
“When the Global Fund shut down the ministry [of health as a recipient], which by far had the most money [from the Fund]… that caused a strain,” he told IRIN/PlusNews. “It took so long for the Global Fund to sign with UNDP… we expected that products… procured by UNDP would arrive in 2010, [but] we’re only seeing the first of those products now.” In Zambia, TB and HIV medication is procured by a consortium of partners.
With the MoH no longer part of this consortium, and UNDP slow to come on board, other members were forced to fill the gaps in the drug supply. “In many cases, SCMS did very expensive emergency procurements, sometimes even bringing in products by plane to fill the gap,” said Proper. He noted that stock-outs at clinics and hospitals were usually short-term, but the larger central medical depots often ran out of stocks for up to six weeks while waiting for emergency shipments to arrive.
Kasonkomona said emergency shipments had been keeping the national ARV programme afloat, and patients were sometimes sent home from clinics with as little as a two-week supply of ARVs. He and other activists alleged that drugs are still being rationed. This means that patients, who often struggle to pay transport costs to the clinic, have to return more frequently, raising the risk of a break in medication and developing resistance to their medicine. At the time of publication the MoH had not yet responded to a request for comment from IRIN/PlusNews.
The causes of drug shortages are complex. Proper said changes in Global Fund distributions, unexpected increases in the consumption of certain drugs, human error and limited storage capacity at clinics were all contributory factors. Nevertheless, Zambia has one of the continent’s lowest stock-out rates, and is one of the few countries to boast long-term projections of ARV needs. Local demand for ARVs also drives a growing number of dispensing facilities that might not have been formally accredited.
These outlets draw on the drug supplies of nearby accredited sites, putting additional pressure on drug stocks. Paying the piper Activists do not understand why the corruption took so long to be exposed, and why those responsible are still not being held accountable. “We knew about this [corruption] more than four years ago [and] wrote to the GF [Global Fund] in Geneva. We were asked to provide evidence, [but] without resources it was impossible for us to do,” Kasonkomona said. TALC and Oxfam’s Civil Society Health Forum have called for the resignation of those in charge of the three principal recipient organizations at the time, including Elizabeth Mataka, executive director of the Zambian National AIDS Network (ZNAN) and a former UN Special Envoy for AIDS in Africa.
Global Fund spokesperson Marcela Rojo said their audit found that ZNAN and the ministries of health and finance had misused $10.7 million of Global Fund money. To date, none of it has been repaid and the bodies responsible had told the Fund they could not repay any money until 2012. The Global Fund audit of ZNAN alleged financial mismanagement that included the purchase of cars for personal use by ZNAN management, exorbitant salaries – sometimes more than double the local sector standard – and funds disbursed to sub-recipients who could not provide auditors with financial records, like the Maureen Mwanawasa Community Initiative, headed by Zambia’s former first lady.
“We feel that ZNAN staff are adequately compensated for the work they do and I don’t think you can do a salary comparison [with other organizations],” Mataka told IRIN/PlusNews. “I think they’re reasonable, and those salaries are approved by the Global Fund.” Mataka, whose role as UN Special Envoy for AIDS in Africa ended in December 2010, denied the allegations of fraud, and said that ZNAN and its sub-recipients have since provided the Global Fund with documentation regarding the grants awarded and their use. Neither the Global Fund nor Zambia’s auditor general have the power to prosecute any principal recipient for alleged misuse or misappropriation of funds, so this will be up to the local courts.
Kasonkomona said TALC and other civil society organizations planned to push for the prosecution of those who were at the helm of the principal recipient organizations. “Our demands are very clear. The four principal recipients – the top officials in charge of the Global Fund [money] – we are asking them to step down to pave the way for a forensic audit,” Kasonkomona said. “We are not witch-hunting – there are people out there who don’t even know the Global Fund money was stolen, but who depend on it. They go to the facility, are told there is no treatment, and have no idea why. But they are Zambians, and they have the right to treatment.”