The appointment of a new Executive Director of the Global Fund to fight AIDS, TB and Malaria on November 15th was expected; and few will be surprised that Mark Dybul, former head of PEPFAR, got the job. His name has been in the frame ever since the previous Executive Director left.
Perhaps more unexpected was the announcement that the Board of the Global Fund has terminated the employment of the Inspector General. Many activists and advocates have not really forgiven the IG for the heavy criticisms faced by the Global Fund about cases of fraudulent expenditure, uncovered by his office (and published in full on the GF website, as per policy). The Global Fund has made it clear that the Office of the Inspector General will remain, and has initiated the process to find a new Inspector General.
As the Global Fund begins a new phase – new leadership, second decade, new funding model, stronger grant management – it will be interesting to see how it pursues the task of monitoring and auditing grants. Certainly, the restructuring of the Fund over the last few months, which has shifted the bulk of staffing into grant management and supervision roles, indicates the intention of paying more attention to what gets funded and how. While this is welcome, however, I hope that actors in recipient countries will also take greater control and ownership. Because if you take a look at any one of the many reports published by the OIG, you’ll notice something a little bit disturbing. Take the Ethiopia report. Here is one of the 86 recommendations:
Recommendation 1 (Significant priority)
To improve the quality of malaria and tuberculosis diagnosis, the FMOH should ensure:
(a) Microscopes are maintained in proper functioning order.
(b) Running water is available in the health facilities.
(c) Refresher training is provided to laboratory technicians based on a needs assessment.
(d) Internal and external quality assurance of the health facility laboratories is conducted as planned and is duly documented.
And here’s another:
Recommendation 75 (High priority)
The PFSA should ensure:
(a) Appropriate racking and other storage media are provided to the facilities in order to facilitate proper storage of health products. In particular, direct storage on the floor as observed in some facilities may lead to products being damaged by moisture hence pallets should be used. Correct handling equipment reduces the risk of injury to workers and damage to stock. Stock organization on shelves and pallets enhances accessibility which facilitates use of first in first out (FIFO) and first expiry first out (FEFO) issuing systems.
(b) Temperature monitoring in storage areas is introduced in order to maintain optimum storage conditions.
So, make sure that broken microscopes get fixed, make sure there is running water, and have proper storage in health facilities. I don’t think the OIG was wrong to include these observations in his report. In fact, if I was conducting an audit and saw these problems, I’d write them up too. Had local supervisors or activists already documented these problems in Ethiopia? If so, how long would it have taken to fix them? Did those responsible even have the resources to fix them? I have no idea, but I am pretty sure that if the success of Global Fund grants depends on a crack team of highly paid international auditors ferretting out problems like this – when the Fund supports services in tens of thousands of health facilities and community organisations – that there is something wrong with the model.
The Global Fund does, of course, provide some support to country-level monitoring and accountability – through the Country Coordinating Mechanisms. But when you compare the oversight tools used by the CCMs to the sorts of data digested by Global Fund portfolio managers and the OIG, there is no comparison – Fund officials have far more information, and far more resources to digest it, than the CCMs. Moreover, the data that CCMs are encouraged to monitor is somewhat abstract. By and large, people that sit on CCMs representing marginalised and underprivileged populations are not trained to interpret spreadsheets and performance ratings.
I’d like to see much more support going to community level monitoring of health services. It does happen, but not nearly enough. And there is evidence that it has a positive impact on how services are provided, and on health outcomes. A fantastic example of where it does happen is in Cameroon, where the organisation Positive Generation supports people with HIV and TB to monitor things like stock outs, provider behaviour, and overpricing of services in 40 treatment facilities in the country.
People who get shoddy services should be able to find out why (i.e., because the microscopes are broken, or the water isn’t running, or the drugs have gone bad); as should people who are refused services or who are subject to human rights violations. And should be able to raise hell and demand changes. They need the support of civil society organisations, human rights organisations, UN agencies, and the Global Fund to do this. I’m hoping that as well as being more diligent in its international grant management, the new Global Fund can find ways of generating greater ownership of the problems in the countries it is funding: not just ownership by governments, but ownership by the people who the Fund was set up to help.