Global Fund toughens stance against corruption
LondonLynn Eaton
Richard Feachem of the Global Fund to Fight AIDS, Tuberculosis, and Malaria tells Lynn Eaton how the fund sees the enforcement of transparency and accountability as a vital step in ensuring results
The recent decision by the Global Fund to Fight AIDS, Tuberculosis, and Malaria to suspend grants to Uganda on the grounds that the funds were misappropriated (BMJ 2005;331:475) feeds the common perception that corruption is more rife in African countries than elsewhere around the world.
Whether corruption is any worse in an African country than, say, in India or El Salvador, is open to debate. But how do aid agencies ensure that their funds are used for the purposes for which they are intended? And, from a medical viewpoint, what are the ramifications for public health if a funding organisation takes the difficult decision to suspend a grant?
Dr Richard Feachem, executive director of the fund, fully accepts the difficulty of what he described as the "life and death" decision they had to make over Uganda. The grants were worth a total of $201m (£113m; €167) over two years, of which $45.4m had already been disbursed.
Speaking at the recent replenishment meeting of the fund in London, he and Hilary Benn, UK secretary of state for international development, told journalists that although it was a hard decision to take, the action would only reinforce trust in the fund.
Dr Feachem also acknowledged that if suspending funding led to the withdrawal of treatments not only would it hasten the death of people who had been receiving the treatments but it could also increase the resistance of the disease to drug treatments in future.
That’s something that really concerns the Ugandan Leonard Okello, who is international head of the HIV and AIDS programme run by the charity Action Aid. The charity’s projects in Uganda received 100 million Ugandan shillings (£30 500; $54 000; €45 000) from the fund.
"When we lose it, that means a lot for us," says Mr Okello. "The big challenge for us is the effect on treatment levels. My biggest worry is continuity of treatment."
Nevertheless he believes the fund made the right decision to suspend funding.
"When something goes wrong, the recipients of the money should be made to know somebody is going to question it," he said. "African government ministers must be held accountable by the citizens of Africa and by those who gave the money."
Until now that has not always happened, he said. "Those who give the money"—he laughingly describes them, tongue in cheek, as the "blue eyed boys"—"are sometimes a bit naive."
The UK Department for International Development, for example, spent more than £345m million on work on HIV and AIDS in developing countries in 2003-4. Yet it was recently criticised by the charity Action Aid for failing to track adequately how its grants were spent.
Mr Okello believes more transparency is the answer, something Dr Feachem agrees with. But Dr Feachem argues that corruption can happen anywhere, not just in African countries.
"It happens in the UK and in the US," he said. "It is a global problem. But there are clearly some settings that are symptomatically corrupt. They tend to be poor countries, but not necessarily African ones. They are ones where there is no framework of good government, where there is no rule of law, where accounting procedures are just not in place.
"All organisations involved in development finance, including the World Bank, face the constant risk of possible misappropriation of funds and of corruption. That’s a fact of life in development finance. The key is to minimise the risk—to have in place oversight systems and to identify problems before they occur."
The Global Fund to Fight AIDS, Tuberculosis, and Malaria, he said, was an "extremely transparent" organisation. All the money it receives or spends is detailed on its website, which he described as "second to none among development agencies."
"The simple fact that everything is on the website is a risk reduction strategy in relation to corruption. It allows everybody to watch what everybody is doing. That includes allowing non-governmental organisations who are distrustful of government to watch government, as well as vice versa," Dr Feachem said.
Another safety mechanism is that the fund agrees to finance schemes only on the basis of actual results. "That is immediately a break on corruption," said Dr Feachem. He argues that if the money has not been spent appropriately then there won’t be any results to show for it, and the project will lose out in the next funding round.
The fund also retains the services of local agents who are responsible for administering the funds and ensuring they are spent appropriately. In most countries the agents will be local outposts of international accountancy firms such as PricewaterhouseCoopers or KPMG.
"They are the agents of the fund—our eyes and ears," he said, explaining that they are retained on a contractual basis, in itself a safeguard against corruption or complacency.
But when misappropriation of funds is discovered, they have to take action, even if they are reluctant do so.
"Wherever we suspend or terminate funding—as we did recently in Myanmar—we are extremely concerned," he says. "Our first concern is that those on treatment stay on treatment. We are working out [how this can be done] in both Myanmar and Uganda. The great case study [of how the fund did this successfully] is the Ukraine, where we suspended funding 18 months ago. Subsequently a Brighton based organisation, the International HIV/AIDS Alliance, has taken over responsibility for schemes in that country."
Dr Feachem admits that it is often harder, but not impossible, for the fund to work in countries where there is a military regime or little open democracy. It is working in Zimbabwe, for example, despite allegations of a fraudulent election in 2005 and the continuing constraints on press freedom, which have been widely condemned outside the country. The fund has just begun an AIDS grant there.
It also works in so called fragile states, those where governments cannot provide safety or security to most of its people. A recent report by the fund of the 19 grants allocated to various fragile states showed that, when the schemes were assessed, 14 were deemed as having an excellent or satisfactory performance. All of which is good news, as the death rate from malaria in fragile states is 13 times that in other countries in the developing world, and the proportion of people with HIV is four times higher.
Although tackling corruption is a major challenge for the fund, the next step, according to one insider, is shifting the mind set so that recipient countries, including those with more highly developed systems, such as Kenya, begin to realise they can’t just take the developed world’s money without any checks.
The money comes with strings attached: in the form of management targets, performance appraisal, and financial review, which—as anyone working in the NHS will tell you—take some getting used to.
Perception of corruption in various countries: overall ranking and score (10 = no corruption)
Ranking Score Finland 1 9.7 UK 11 8.6 US 17 7.5 Botswana 31 6.0 South Africa 44 4.6 China 71 3.4 Gambia 90 (joint) 2.8 India 90 (joint) 2.8 Eritrea 102 (joint) 2.6 Uganda 102 (joint) 2.6 Zambia 102 (joint) 2.6 Yemen 112 2.2 Sudan 122 2.2 Kenya 129 2.1 Angola 133 (joint) 2.0 Democratic Republic of Congo 133 (joint) 2.0 Chad 142 1.7 Nigeria 144 1.6 Bangladesh 145 (joint worst) 1.5 Haiti 145 (joint worst) 1.5
Source: Transparency International (www.tranparency.org ), a Berlin based organisation that monitors perceptions of corruption worldwide and publishes an annual ranking. The people surveyed included business people and country analysts.