The distribution of insecticide-treated bed nets (ITN), both in the most populated and the more isolated regions of sub-Saharan Africa is proving to be a crucial step in the fight against malaria.
Credit: Stephenie Hollyman/WHO
The fight against malaria in Uganda suffered a “significant setback” following the two-month suspension of funding worth hundreds of millions of dollars by the Global Fund to Fight AIDS, Tuberculosis and Malaria, according to John Rwakimari, the head of the country’s malaria control programme.

The Global Fund suspended five grants totalling more than US $200 million in August 2005 after an independent investigation found evidence of a “serious mismanagement of funds.” The suspension of grants was lifted in November after the Ugandan government took steps to restructure the way funds are handled.

A disproportionately high toll

The World Health Organization (WHO) estimates that between 70,000 and 110,000 children die as a direct result of the disease in the East African country each year. As in many other sub-Saharan African countries, malaria is the number one killer disease in Uganda.

The incidence rate of malaria in Uganda increased from 5.5 million to more than 16 million since the worldwide Roll Back Malaria Partnership started in 1998. In a country with a population of 25 million, this represents a disproportionately high level of incidence.

Mirroring the same findings in neighbouring countries, it is children under age five and pregnant women who are the most vulnerable. Every day, approximately 400 people in Uganda die of malaria, a parasite transmitted by mosquitoes that have become increasingly resistant to existing medications.

The international Roll Back Malaria programme’s prevention policy has focused on providing insecticide-treated nets in Uganda’s malaria-endemic regions. To date, Uganda has secured grants from the Global Fund worth nearly $90 million to buy more effective drugs and improve measures to combat the disease.

The Ugandan government caused alarm among international donors when it recently announced it intended to use the insecticide DDT (dichlorodiphenyltrichloroethane) to fight malaria. Although the pesticide is banned under international convention except in the event of a “public health crisis,” the health ministry in Uganda argued that the use of DDT is a cost-effective, long-term preventive measure that would reduce the economic burden placed on the country’s health services by malaria. Meanwhile, environmentalists insist DDT is a dangerous toxin, harmful to both the environment and human health.

Set backs for the programme

The suspension of funds in 2005 delayed the distribution of highly subsidised insecticide-treated bed nets and the provision of new anti-malarial medication. The national effort can ill afford any set backs in its work, but the case of Uganda illustrates some of the problems the Global Fund faces in its endeavors to disburse money to a wide variety of countries with varying levels of transparency and accountability.

Rwakimari denied claims that malaria patients had died as a consequence of the move, but he admitted that the suspension did lead to a “direct shortage in anti-malarial drugs and slowed down the distribution of mosquito nets.”

Robert Azairwe, WHO programme officer for malaria control, also admitted that the postponement of Global Fund money did not help the funding shortfalls which are already limiting the scheme’s success.

“During the period of the suspension we hoped to have distributed 1.8 million highly subsidised treated nets, targeting children under the age of five and pregnant women,” Azairwe said.

“Furthermore,” he added, “we had hoped to begin implementation of a new drug policy in November since the malaria parasite is becoming increasingly resistant to old medication. This is now unlikely to begin until February 2006.”

The suspension prompted debate in Uganda and internationally on whether reputedly corrupt governments should be entrusted with grants worth hundreds of millions of dollars from a global public-private partnership.

Mohammed Kezaala, permanent secretary for the Ugandan ministry of health, recently told a an independent commission of inquiry established by the Ugandan President Yoweri Museveni that he had released money from the Global Fund to three senior health ministers during the 2004 Christmas season.

The commission released a list of over 300 beneficiaries of the funds, but doubts were cast over the validity of some of these recipients. To qualify for grants, the Global Fund stipulates that NGOs must have been in existence more than a year before the health ministry’s Project Management Unit (PMU) responsible for the disbursement of funds was established. This was not the case for some beneficiaries.

Investigations

An investigation by the Daily Monitor, Uganda’s leading independent newspaper, revealed that much of the money went to NGOs linked to members of parliament, ministers and other government officials. While the Global Fund decided that the mismanagement of funds did not amount to “corruption or embezzlement,” it did suspend grants to the PMU. The PMU was subsequently disbanded in August 2005, shortly after the suspension of funding was announced.

Leading figures from Uganda’s civil society have responded by calling for a re-think in the philosophy and processes behind the Global Fund’s allocation of money.

Retired Maj Rubaramira Ruranga, a prominent AIDS activist, described the Global Fund’s model of funding as “flawed” and “open to corruption.”

“When you put this money into a ministry which is having financial problems you must expect problems,” he said. “I think the best thing to do is to give the money to national and international nongovernmental organisations that will not be influenced by government so they can manage a clean policy on HIV, tuberculosis and malaria.”

The Global Fund acknowledged that “in many countries the principal recipient may be housed within a government ministry.” It added, however, that grants could only be proposed through a country coordinating mechanism that must “contain a broad representation, a partnership between all stakeholder groups within the country, including government, civil society, the private sector and affected communities.”

WHO has warned that funding to combat malaria must not be sparse and sporadic, but adequate, with a long-term focus that looks beyond immediate targets. The Global Fund recently rejected a proposal by Uganda for a further $85 million to help combat the disease that is so endemic in the country. The ministry of health said that the implementation of a policy targeting the disease would always be at risk of financial shortfalls until Uganda reduced its reliance on foreign donors and NGOs for funding.

“At the moment we have no contingency plan for when funding is withdrawn,” Rwakimari said.
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